By Z. Ressel. Wesley College. 2019.

The rate at which a drug enters the body determines for another may give rise to clinical problems unless the the onset of its pharmacological action purchase isoptin uk, and also influences the preparations are ‘bioequivalent’ purchase isoptin 240 mg. Regulatory authorities intensity and sometimes the duration of its action buy cheap isoptin 240 mg line, and is therefore require evidence of bioequivalence before important in addition to the completeness of absorption purchase isoptin once a day. They provide an approach to improving (brand named or generic) are sufficiently similar for their sub- absorption and distribution. If evidence is presented that a new One approach to improving absorption or distribution to a rel- generic product can be treated as therapeutically equivalent to atively inaccessible tissue (e. This does not imply that all possible pharmacokinetic absorbed and from which active drug is liberated after absorp- parameters are identical between the two products, but that tion. There are two main mechanisms of Oral drug administration may be used to produce local effects drug absorption by the gut (Figure 4. Non-polar lipid-soluble dependent acrylic coat that degrades at alkaline pH as in the agents are well absorbed from the gut, mainly from the small intestine, because of the enormous absorptive surface area provided by villi and microvilli. Naturally occurring polar substances, including sugars, amino acids and vitamins, are Relatively well- Relatively poorly absorbed and/or absorbed and/or absorbed by active or facilitated transport mechanisms. Drugs good tissue poor tissue that are analogues of such molecules compete with them for penetration penetration transport via the carrier. The following advantages have been claimed for the rec- tal route of administration of systemically active drugs: Prolonged action and sustained-release preparations 1. Exposure to the acidity of the gastric juice and to digestive Some drugs with short elimination half-lives need to be adminis- enzymes is avoided. The portal circulation is partly bypassed, reducing ence to the prescribed regimen difficult for the patient. The aim of such Rectal diazepam is useful for controlling status epilepticus in sustained-release preparations is to release a steady ‘infusion’ of children. Metronidazole is well absorbed when administered drug into the gut lumen for absorption during transit through rectally, and is less expensive than intravenous preparations. Reduced dosing frequency may improve However, there are usually more reliable alternatives, and compliance and, in the case of some drugs (e. Other limitations of slow-release preparations are: Drugs are applied topically to treat skin disease (Chapter 51). Transit time through the small intestine is about six hours, Systemic absorption via the skin can cause undesirable effects, so once daily dosing may lead to unacceptably low trough for example in the case of potent glucocorticoids, but the concentrations. If the gut lumen is narrowed or intestinal transit is slow, temic therapeutic effect (e. Osmosin™, an osmotically released formulation of Factors affecting percutaneous drug absorption include: indometacin, had to be withdrawn because it caused 1. Plastic-film occlusion (sometimes employed by dermatologists) increases hydration. The Sublingual administration has distinct advantages over oral physical chemistry of these mixtures may be very complex administration (i. Glyceryl trinitrate, buprenorphine and fentanyl are enhances absorption, and solutions penetrate best of all; given sublingually for this reason. Sublingual adminis- important when treating infants who have a relatively tration provides short-term effects which can be terminated by large surface area to volume ratio. The rate of absorption is increased when the solution is Drugs, notably steroids, β2-adrenoceptor agonists and mus- distributed throughout a large volume of muscle. Dispersion is carinic receptor antagonists, are inhaled as aerosols or particles enhanced by massage of the injection site. Nebulized antibiotics are the injection site is governed by muscle blood flow, and this also sometimes used in children with cystic fibrosis and recur- varies from site to site (deltoid vastus lateralis gluteus max- rent Pseudomonas infections. Blood flow to muscle is increased by exercise and absorp- temic absorption are desirable. For example, ipratropium is a tion rates are increased in all sites after exercise. Conversely, quaternary ammonium ion analogue of atropine which is shock, heart failure or other conditions that decrease muscle highly polar, and is consequently poorly absorbed and has blood flow reduce absorption. A large fraction of an The drug must be sufficiently water soluble to remain in ‘inhaled’ dose of salbutamol is in fact swallowed. This is a the bioavailability of swallowed salbutamol is low due to inac- problem for some drugs, including phenytoin, diazepam and tivation in the gut wall, so systemic effects such as tremor are digoxin, as crystallization and/or poor absorption occur when minimized in comparison to effects on the bronchioles. Slow absorption is useful in some circum- phase, since the total respiratory surface area is about 60m2, stances where appreciable concentrations of drug are required through which only 60mL blood are percolating in the capil- for prolonged periods. This is exploited in the case of volatile anaesthetics, as used to improve compliance in psychiatric patients (e. Anasal/inhaled preparation of insulin decanoate ester of fluphenazine which is slowly hydrolysed to was introduced for type 2 diabetes (Chapter 37), but was not release active free drug). This has opened up an area of therapeutics than the oral route; that was previously limited by the inconvenience of repeated 7. Absorption is retarded by immobiliza- tion, reduction of blood flow by a tourniquet and local cooling. Drugs are administered topically to these sites for their local Adrenaline incorporated into an injection (e. Occasionally, important clinically, most notably in the treatment of insulin- they are absorbed in sufficient quantity to have undesirable sys- dependent diabetics, different rates of absorption being temic effects, such as worsening of bronchospasm in asthmatics achieved by different insulin preparations (see Chapter 37). Penicillin used to be administered intrathecally to patients with pneumococcal meningitis, because of the belief that it penetrated the blood–brain barrier inadequately. Intravenous penicillin should now This has the following advantages: always be used for meningitis, since penicillin is a predictable 1. It is also used for drugs that are too painful Key points or toxic to be given intramuscularly. Cytotoxic drugs must not be allowed to leak from the vein or considerable local • Oral – generally safe and convenient • Buccal/sublingual – circumvents presystemic metabolism damage and pain will result as many of them are severe • Rectal – useful in patients who are vomiting vesicants (e. This is • Lungs – volatile anaesthetics essential for drugs such as sodium nitroprusside and • Nasal – useful absorption of some peptides (e. High concentrations result if the drug is given too rapidly – potentially very dangerous, as a high concentration the right heart receives the highest concentration. Embolism of foreign particles or air, sepsis or • Intrathecal – specialized use by anaesthetists thrombosis. Inadvertent intra-arterial injection can cause arterial Case history spasm and peripheral gangrene. The health visitor is concerned about an eight-month-old girl who is failing to grow. On further enquiry, the mother tells you that she has been This route provides access to the central nervous system for applying clobetasone, which she had been prescribed her- self for eczema, to the baby’s napkin area. The mother stops using the clobetasone this route should never be used without adequate training. It is prescribed for its top-ical effect, but can penetrate disability is such that extra care must be taken in checking that skin, especially of an infant. Examples of drugs used appropriate for an adult would readily cover a large frac- in this way include methotrexate and local anaesthetics (e. Microspheres for controlled release drug deliv- Therapeutic Drug Carrier Systems 2003; 20: 153–2. The pharmacological activity of many drugs is reduced or Hepatocyte endoplasmic reticulum is particularly important, abolished by enzymatic processes, and drug metabolism is one but the cytosol and mitochondria are also involved. These metabolic delayed effects of the long-lasting metabolite as it accumulates reactions include oxidation, reduction and hydrolysis. Monoamine oxidase is found in liver, kidney, intestine and nervous tissue, and its substrates include catecholamines Glycine and glutamine are the amino acids chiefly involved in conjugation reactions in humans. Hepatocellular damage depletes the intracellular pool of these amino acids, thus restricting this pathway. Acetylating – Hydrolysis – Glucuronidation – Sulphation activity resides in the cytosol and occurs in leucocytes, gastro- – Mercaptopuric intestinal epithelium and the liver (in reticulo-endothelial rather acid formation than parenchymal cells). Some patients inherit a deficiency of glu- with thiol donors such as N-acetyl cysteine or methionine to curonide formation that presents clinically as a non- increase the endogenous supply of reduced glutathione. Drugs that are normally conju- gated via this pathway aggravate jaundice in such patients.

If the researchers believe that their treatment is going to work purchase generic isoptin pills, why would they deprive some of their participants cheap isoptin 40mg free shipping, who are in need of help purchase isoptin 240 mg with mastercard, of the possibility for improvement by putting them in a control group? Social skills training augments the effectiveness of cognitive behavioral group therapy for social anxiety disorder purchase isoptin 40 mg online. These studies are advantageous because they compare the specific effects of one type of treatment with another, while allowing all patients to get treatment. Research Focus: Meta-Analyzing Clinical Outcomes Because there are thousands of studies testing the effectiveness of psychotherapy, and the independent and dependent variables in the studies vary widely, the results are often combined using a meta-analysis. A meta- analysis is a statistical technique that uses the results of existing studies to integrate and draw conclusions about those studies. In one important meta-analysis analyzing the effect of psychotherapy, Smith, Glass, and Miller [7] (1980) summarized studies that compared different types of therapy or that compared the effectiveness of therapy against a control group. To find the studies, the researchers systematically searched computer databases and the reference sections of previous research reports to locate every study that met the inclusion criteria. Over 475 studies were located, and these studies used over 10,000 research participants. The results of each of these studies were systematically coded, and a measure of the effectiveness of treatment known as the effect size was created for each study. Smith and her colleagues found that the average effect size for the influence of therapy was 0. What this means is that, overall, receiving psychotherapy for behavioral problems is substantially better for the individual than not receiving therapy (Figure 13. Although they did not measure it, psychotherapy presumably has large societal benefits as well—the cost of the therapy is likely more than made up for by the increased productivity of those who receive it. On the basis of these and other meta-analyses, a list ofempirically supported therapies—that is, therapies that are known to be effective—has been [11] developed (Chambless & Hollon, 1998; Hollon, Stewart, & Strunk (2006). What this means is that a good part of the effect of therapy is nonspecific, in the sense that simply coming to any type of therapy is helpful in comparison to not coming. This is true partly because there are fewer distinctions among the ways that different therapies are practiced than the theoretical differences among them would suggest. What a good therapist practicing psychodynamic approaches does in therapy is often not much different from what a humanist or a cognitive- behavioral therapist does, and so no one approach is really likely to be better than the other. This is why many self-help groups are also likely to be effective and perhaps why having a psychiatric service dog may also make us feel better. Effectiveness of Biomedical Therapies Although there are fewer of them because fewer studies have been conducted, meta-analyses also support the effectiveness of drug therapies for psychological disorder. People who take antidepressants for mood disorders or antianxiety medications for anxiety disorders almost always report feeling better, although drugs are less helpful for phobic disorder and obsessive-compulsive disorder. Some of these improvements are almost certainly the result [16] of placebo effects (Cardeña & Kirsch, 2000), but the medications do work, at least in the short term. One problem with drug therapies is that although they provide temporary relief, they don‘t treat the underlying cause of the disorder. In addition many drugs have negative side effects, and some also have the potential for addiction and abuse. Different people have different reactions, and all drugs carry Attributed to Charles Stangor Saylor. As a result, although these drugs are frequently prescribed, doctors attempt to prescribe the lowest doses possible for the shortest possible periods of time. Older patients face special difficulties when they take medications for mental illness. Older people are more sensitive to drugs, and drug interactions are more likely because older patients tend to take a variety of different drugs every day. They are more likely to forget to take their pills, to take too many or too few, or to mix them up due to poor eyesight or faulty memory. Like all types of drugs, medications used in the treatment of mental illnesses can carry risks to an unborn infant. Tranquilizers should not be taken by women who are pregnant or expecting to become pregnant, because they may cause birth defects or other infant problems, especially if taken during the first trimester. Food and [18] [19] Drug Administration, 2004), as do antipsychotics (Diav-Citrin et al. Decisions on medication should be carefully weighed and based on each person‘s needs and circumstances. Medications should be selected based on available scientific research, and they should be prescribed at the lowest possible dose. Effectiveness of Social-Community Approaches Measuring the effectiveness of community action approaches to mental health is difficult because they occur in community settings and impact a wide variety of people, and it is difficult to find and assess valid outcome measures. Nevertheless, research has found that a variety of community interventions can be effective in preventing a variety of psychological disorders [20] (Price, Cowen, Lorion, & Ramos-McKay,1988). And the average blood- lead levels among children have fallen approximately 80% since the late 1970s as a result of federal legislation designed to remove lead paint from housing (Centers for Disease Control and [22] Prevention, 2000). Although some of the many community-based programs designed to reduce alcohol, tobacco, and drug abuse; violence and delinquency; and mental illness have been successful, the changes brought about by even the best of these programs are, on average, modest (Wandersman & [23] Florin, 2003; Wilson, Gottfredson, & Najaka, 2001). What is important is that community members continue to work with researchers to help determine which aspects of which programs are most effective, and to concentrate efforts on the most productive approaches (Weissberg, Kumpfer, & Seligman, [24] 2003). The most beneficial preventive interventions for young people involve coordinated, systemic efforts to enhance their social and emotional competence and health. Many psychologists continue to work to promote policies that support community prevention as a model of preventing disorder. All good therapies give people hope and help them think more carefully about themselves and about their relationships with others. Given your knowledge about the effectiveness of therapies, what approaches would you take if you were making recommendations for a person who is seeking treatment for severe depression? The Scientific Review of Mental Health Practice: Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work, 1(1), 11–22. Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: A randomized controlled trial with a three-year follow-up. Efficacy of paroxetine in the treatment of adolescent major depression: A randomized, controlled trial. Social skills training augments the effectiveness of cognitive behavioral group therapy for social anxiety disorder. Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing. Cognitive and behavioral treatments for anxiety disorders: A review of meta-analytic findings. Enduring effects for cognitive therapy in the treatment of depression and anxiety. Psychotherapy for depression in adults: A meta- analysis of comparative outcome studies. True or false: The placebo effect as seen in drug studies is definitive proof that the mind can bring about clinically relevant changes in the body: What is so special about the placebo effect? Selective serotonin reuptake inhibitors for unipolar depression: A systematic review of classic long-term randomized controlled trials. Selective publication of antidepressant trials and its influence on apparent efficacy. First-trimester use of selective serotonin- reuptake inhibitors and the risk of birth defects. Safety of haloperidol and penfluridol in pregnancy: A multicenter, prospective, controlled study. Blood lead levels in young children: United States and selected states, 1996–1999. Psychologists base this treatment and prevention of disorder on the bio-psycho-social model, which proposes that disorder has biological, psychological, and social causes, and that each of these aspects can be the focus of reducing disorder. The fundamental aspect of psychotherapy is that the patient directly confronts the disorder and works with the therapist to help reduce it. Psychodynamic therapy (also known as psychoanalysis) is a psychological treatment based on Freudian and neo-Freudian personality theories. The analyst engages with the patient in one-on- one sessions during which the patient verbalizes his or her thoughts through free associations and by reporting on his or her dreams. The goal of the therapy is to help the patient develop insight— that is, an understanding of the unconscious causes of the disorder. Humanistic therapy is a psychological treatment based on the personality theories of Carl Rogers and other humanistic psychologists. Humanistic therapies attempt to promote growth and responsibility by helping clients consider their own situations and the world around them and how they can work to achieve their life goals.

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Answer the question asked (not the one you would like it to have been) concisely and carefully purchase isoptin 240mg otc, and then wait for the next question generic 120 mg isoptin with visa. There is no need to fill all silences with words; the judge and others will be making notes order 40mg isoptin otc, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly buy cheap isoptin 120 mg on line. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense. You may be the only person who can retrieve a medical emergency in the cells—picking up a subdural hematoma, diabetic ketoacidosis, or coro- nary thrombosis that the detaining authority has misinterpreted as drunken- ness, indigestion, or simply “obstructive behavior. Get it wrong, and you may not only fail to prevent an avoidable death but also may lay yourself open to criminal, civil, and disciplinary proceedings. You clearly owe a duty of care to those who engage your services, for that is well-established law. The issue of whether a forensic physician owes a wider duty to the victims of alleged crime was decided in the English Court of Appeal during 1999 (35). On December 20, the judge accepted a defense submission of no case to answer and directed the jury to return a verdict of not guilty. She claimed to suffer persistent stress and other psychological sequelae from fail- ing to secure the conviction of her alleged assailant and knowing that he is still at large in the vicinity. The claimant did not contend that there was any general duty of care on the part of a witness actionable in damages at the suit of another witness who may suffer loss and damage through the failure of the first witness to attend and give evidence in accordance with his or her witness statement. When the case came before the Court of Appeal, Lord Justice Stuart- Smith stated that the attempt to formulate a duty of care as pleaded, “is wholly misconceived. If a duty of care exists at all, it is a duty to prevent the plaintiff from suffering injury, loss or damage of the type in question, in this case psychiatric injury. A failure to attend to give evidence could be a breach of such duty, but it is not the duty itself. It seems to me that she must have owed a duty of care to carry out any examination with reasonable care, and thus, for example, not to make matters worse by causing injury to the plaintiff. Revised interim guidelines on confidentiality for police surgeons in England, Wales and Northern Ireland. Association of Police Surgeons (now the Association of Forensic Physi- cians), East Kilbride. The Stationery Office, London, 1999; and on the Department of Constitutional Affairs (formerly Lord Chancellor’s Department). Sexual Assualt Examination 61 Chapter 3 Sexual Assault Examination Deborah Rogers and Mary Newton 1. All health professionals who have the potential to encounter victims of sexual assaults should have some understanding of the acute and chronic health problems that may ensue from an assault. However, the pri- mary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by doctors and nurses who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training. There are many types of sexual assault, only some of which involve pen- etration of a body cavity. This chapter encourages the practitioner to under- take an evidence-based forensic medical examination and to consider the nature of the allegation, persistence data, and any available intelligence. The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault. Although the first concern of the forensic practitioner is always the medical care of the patient, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect, identification of the assailant, and the prosecution of the case. Thus, it is imper- ative that all forensic practitioners understand the basic principles of the foren- sic analysis. Thereafter, the text is divided into sections covering the relevant body areas and fluids. Each body cavity section commences with information regard- From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. This specialist knowledge is manda- tory for the reliable documentation and interpretation of any medical findings. The practical aspects—which samples to obtain, how to obtain them, and the clinical details required by the forensic scientist—are then addressed, because this takes priority over the clinical forensic assessment. The medical findings in cases of sexual assault should always be addressed in the context of the injuries and other medical problems associated with con- sensual sexual practices. Therefore, each section summarizes the information that is available in the literature regarding the noninfectious medical compli- cations of consensual sexual practices and possible nonsexual explanations for the findings. The type, site, and frequency of the injuries described in asso- ciation with sexual assaults that relate to each body area are then discussed. Unfortunately, space does not allow for a critical appraisal of all the chronic medical findings purported to be associated with child sexual abuse, and the reader should refer to more substantive texts and review papers for this infor- mation (1–3). Throughout all the stages of the clinical forensic assessment, the forensic practitioner must avoid partisanship while remaining sensitive to the immense psychological and physical trauma that a complainant may have incurred. Although presented at the end of the chapter, the continuing care of the com- plainant is essentially an ongoing process throughout and beyond the primary clinical forensic assessment. Immediate Care The first health care professional to encounter the patient must give urgent attention to any immediate medical needs that are apparent, e. Nonetheless, it may be possible to have a health care worker retain any clothing or sanitary wear that is removed from a complainant until this can be handed to someone with specialist knowledge of forensic packag- ing. Timing of the Examination Although in general terms the clinical forensic assessment should occur as soon as possible, reference to the persistence data given under the relevant sections will help the forensic practitioner determine whether the examination of a complainant should be conducted during out-of-office hours or deferred Sexual Assualt Examination 63 until the next day. Even when the nature of the assault suggests there is unlikely to be any forensic evidence, the timing of the examination should be influenced by the speed with which clinical signs, such as reddening, will fade.

Beneath the lunula is the nail matrix discount isoptin 120mg line, a region of thickened strata where mitosis pushes previously formed cornified cells forward generic 40 mg isoptin visa, making the nail grow purchase 40 mg isoptin with mastercard. Under the free edge of the nail isoptin 40 mg with amex, the stratum corneum thickens to form the hypony- chium. Nails are pinkish in color because of hemoglobin in the underlying capillaries, which are visible through the translucent cells of the nail. Nails function as an aid to grasping, as a tool for manipulating small objects, and as protection against trauma to the ends of fingers and toes. Sweating the details Humans perspire over nearly every inch of skin, but anyone with sweaty palms or smelly feet can attest to the fact that sweat glands are most numerous in the palms and soles, with the forehead running a close third. Both are coiled tubules embedded in the dermis or subcutaneous layer composed of simple columnar cells. Eccrine glands are distributed widely over the body — an average adult has roughly 3 million of them — and produce the watery, salty secretion you know as sweat. The sympathetic division of the autonomic nervous system controls when and how much perspiration is secreted depending on how hot the body becomes. About 99 percent of eccrine-type sweat is water, but the remaining 1 percent is a mixture of sodium chlo- ride and other salts, uric acid, urea, amino acids, ammonia, sugar, lactic acid, and ascorbic acid. Apocrine sweat glands are located primarily in armpits (known as the axillary region) and the groin area. Usually associated with hair follicles, they produce a white, cloudy secretion that contains organic matter. Although apocrine-type sweat contains the same basic components as eccrine sweat and also is odorless when first secreted, bac- teria quickly begin to break down its additional fatty acids and proteins — explaining the post-exercise underarm stench. In addition to exercise, sexual and other emotional stimuli can cause contraction of cells around these glands, releasing sweat. Getting an earful The occasionally troublesome yellowish substance known as earwax is secreted in the outer part of the ear canal from modified sudoriferous glands called ceruminous glands (the Latin word cera means “wax”). Lying within the subcutaneous layer of the ear canal, these glands have ducts that either open directly into the ear canal or empty into the ducts of nearby sebaceous glands. Working with ear hairs, cerumen traps any foreign particles before they reach the eardrum. As the cerumen dries, it flakes and falls from the ear, carrying particles out of the ear canal. The muscle that straightens a hair and puts pressure on a gland causing it to secrete is the a. The bulb of the follicle of a hair contains epithelial cells (germinating cells) that are continu- ous with the a. This gland contains true sweat, fatty acids, and proteins, and acquires an unpleasant odor when bacteria breaks down the organic molecules it secretes. The gland that secretes an oily mixture of cholesterol, fats, and other substances into hair fol- licles to keep hair and skin soft, pliable, and waterproof is the a. Eccrine gland Chapter 7: It’s Skin Deep: The Integumentary System 125 Answers to Questions on the Skin The following are answers to the practice questions presented in this chapter. This layer also is called the stratum germinativum, but a simpler memory tool is simply to associate it with the “base” of the epidermis. Here’s a fun experiment: Turn off the lights, press your fingers together, and hold a flashlight under them. The description in this question sounds like a tough structure, so it may help you to remember that the reticular layer is what’s used to make leather from animal hides. Keratohyalin even- tually becomes keratin, so think of the layer where the cells are starting to die off. Reticular means net-like; it makes sense that this netting lies between the dermis and the hypodermis. Ever noticed how kids have more freckles at the end of a long summer spent outdoors? While it’s true that sev- eral different nerves are involved in the overall sense of touch, the Meissner’s are the most responsive to touch. Specific temperatures may seem tough to remember, but look at it this way: When it’s 45 degrees F, you definitely need a jacket. But when it’s 68 degrees F, you’ll want to carry a light jacket in case it gets colder. Recall that the prefix ep– refers to “upon” or “around,” whereas the prefix hypo– refers to “below” or “under. The Latin translation of this word is “small cavity” or “sac,” so it makes sense that this would be an origination place. This answer just means that your hair won’t turn orange, not necessarily that it will fall out of your scalp. Don’t forget, though, that this layer also is called the stratum basale, or base stratum. B This gland contains true sweat, fatty acids, and proteins, and acquires an unpleasant odor when bacteria breaks down the organic molecules it secretes. D The gland that secretes an oily mixture of cholesterol, fats, and other substances into hair follicles to keep hair and skin soft, pliable, and waterproof is the b. Each of the chapters in this part delves into a different major body system, starting with the respiratory system and what a few deep breaths can do for the human machine. Next up is the digestive system, fueling the system with food; you follow a mouthful of food from its entry in the mouth to expulsion of waste after every possi- ble nutrient has been wrung from it. We check in on the cir- culatory system and its blood-filled internal transit routes that carry both nutrients and oxygen to every nook and cranny of the body. Then it’s on to the lymphatic system’s distribution of crucial immune system functions. Of course, all this supply and transport is bound to lead to a waste issue; we close out this part with a look at how the urinary system collects the body’s trash and dispenses with it. Chapter 8 Oxygenating the Machine: The Respiratory System In This Chapter Tracking respiration: In with oxygen, out with carbon dioxide Identifying the organs and muscles of the respiratory tract Taking note of common pulmonary diseases eople need lots of things to survive, but the most urgent need from moment to moment Pis oxygen. But if we have reserves of the other things we need — carbohydrates, fats, and proteins — why don’t we have some kind of storehouse of oxygen, too? It’s readily available in the air around us, so we’ve never needed to evolve a means for storing it. Nonetheless, our stored food supplies would be useless without oxygen; our bodies can’t metabolize the energy they need from these substances without a constant stream of oxygen to keep things percolating along. Conveniently, breathing in fulfills our need for oxygen and breathing out fulfills our need to expel carbon dioxide. In this chapter, you get a quick review of Mother Nature’s dual-purpose system and plenty of opportunities to test your knowledge about the lungs and other parts of the respiratory system. Anoxia: Oxygen deficiency in which the cells either don’t have or can’t utilize sufficient oxygen to perform normal functions. Asphyxia: Lack of oxygen with an increase in carbon dioxide in the blood and tissues; accompanied by a feeling of suffocation leading to coma. Expiration or exhalation: The diaphragm returns to its domed shape as the muscle fibers relax, via elastic recoil of the lungs and tissues lining the thoracic cavity, the external intercostal muscles relax, and the internal intercostal muscles contract. This movement pulls the ribs back into place, decreasing the volume of the thoracic cavity and increasing pressure, forcing air out of the lungs. Inspiration or inhalation: When the muscles of the diaphragm contract, its dome shape flattens; simultaneously, the contraction of the external intercostal muscles pulls the ribs upward and increases the volume of the thoracic cavity, decreasing the intra-alveolar pressure. The pressure difference between the atmosphere and the lungs diffuses air into the respiratory tract. Mediastinum: The region between the lungs extending from the sternum ven- trally (at the front) to the thoracic vertebrae dorsally (at the back), and superi- orly (top) from the entrance of the thoracic cavity to the diaphragm inferiorly (at the bottom). Minimal air: The volume of air in the lungs when they’re completely collapsed (150 cubic centimeters in an adult). Residual air: The volume of air remaining in the lungs after the most forceful expiration (1,200 cubic centimeters in an adult). Respiratory centers: Nerve centers for regulating breathing located in the medulla oblongata, or brain stem. Tidal air: The volume of air inspired and expired in the resting state (500 cubic centimeters in an adult). Vital capacity: The volume of air moved by the most forceful expiration after a maximum inspiration.

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The coroner must be notified to determine followed by acceptance of the loss discount isoptin 40 mg with visa, is which of the need for an autopsy generic 240mg isoptin with mastercard. Explain the entire condition in detail complained of frequent headaches and loss of regardless of what the patient may already appetite buy isoptin 240mg without a prescription. Which of the following diagnoses specifically the patient from your goal of dispensing addresses human response to loss and impend- information purchase isoptin with american express. In a living will, a patient appoints an agent Circle the letters that correspond to the best that he/she trusts to make decisions if answers for each question. Which of the following are impending signs of healthcare team to resuscitate a terminal death? Increased gastrointestinal activity describe the process of preparing a death certificate? Lowered blood pressure health department, which compiles many statistics from the information. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. It is the nurse’s responsibility to ensure Match the term in Part A with the appropriate that the physician has signed a death definition listed in Part B. A death certificate is signed by the patholo- gist, the coroner, and others in special a. The period of acceptance of loss during dentures or other prostheses which the person learns to deal with the e. Arranging for family members to view loss the body before it is discharged to the 2. A type of loss in which a person displays mortician loss and grief behaviors for a loss that has f. Attending the funeral of a deceased yet to take place patient and making follow-up visits to 3. A type of loss that can be recognized by the family others as well as by the person sustaining the loss 4. When an older man grieves for the loss of his youth, this type of loss is known as 6. Match Engel’s six stages of grief listed in Part A with the appropriate conversation that may 4. Abnormal or distorted grief that may be unre- occur during each stage listed in Part B. Resolving the loss Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. A slow-code order may be written on the chart Maybe my husband and I can eat out of a terminally ill patient if the patient or this Sunday. Terminal weaning is the gradual withdrawal of wish I could be more like her with my mechanical ventilation from a patient with a kids. The nurse assumes responsibility for handling to pray for my mother’s soul and to help and filing the death certificate with proper me get over her death. A person experiencing abbreviated grief may have trouble expressing feelings of loss or may a. In the denial and isolation stage of dying, the patient expresses rage and hostility and adopts a “why me? Briefly describe the following stages of dying, is usually responsible for deciding what and according to Kübler-Ross. True False Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. List three arguments in favor of and against assisted suicide and direct voluntary euthanasia. List three goals for nurses who wish to become effective in caring for patients experi- encing loss, grief, or dying and death. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. A 22-year-old male athlete has his left leg amputated after it was crushed in a car 3. How long did it take you to resolve the loss and get back to normal life activities? How can you use your nursing process skills to answer the this knowledge in your care of patients? Although both LeRoy and Michael “did the Use the following expanded scenario from bathhouse scene” in the early 1980s and had Chapter 43 in your textbook to answer the multiple unprotected sexual encounters, they questions below. Michael has been in and out the hospital after her water broke, and labor of the hospital during the past 3 years and is begins 7 weeks early. Yvonne is single very supportive of Michael throughout the dif- and desperately wants to be a mother. She ferent phases of his illness but at present had a normal pregnancy up to this point and seems to be “losing it. Malic in a don’t think he’s able to deal with the fact that manner that respects her right to privacy I’m dying,” Michael tells you. When the hospice nurse calls Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Identify pertinent patient data by placing a Personal strengths: single underline beneath the objective data in the patient care study and a double underline beneath the subjective data. Pretend that you are performing a nursing page 304 to develop a three-part diagnostic assessment of LeRoy after the plan of care is statement and related plan of care for this implemented. Write down the patient and personal nursing strengths you hope to draw on as you assist this patient to better health. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. For the purposes of this exercise, develop the one patient goal that demonstrates a direct resolution of the patient problem identified in the nursing diagnosis. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. You should not touch the unconscious Circle the letter that corresponds to the best patient unnecessarily because it may answer for each question. You should keep the environmental noise home for the past 5 years no longer responds level high to help stimulate the patient. Different personality types demand the lucinates simply to maintain an optimal level same level of stimulation. An unconscious patient is assigned to your decreased attention span, and cannot concen- unit. Which of the following effects of sensory follow which of the following guidelines for deprivation might he be experiencing? Which of the following statements accurately absent functioning in one or more senses? Sensory overstimulation and is independent of stimulation received during childhood. It is recommended that medically fragile Multiple Response Questions infants have greater light and visual and Circle the letters that correspond to the best vestibular stimulation. Which of the following conditions must be present for a person to receive the data neces- e. Which of the following are guidelines that should be followed when caring for visually d. Orient the person to the arrangement of tastes, and smells the room and its furnishings. Difficulty with memory, problem solving, follow when dealing with patients with hear- and task performance ing impairments?

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Help client explore angry feelings so that they may be di- rected toward the intended object or person buy isoptin with mastercard. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues order cheap isoptin on-line. Help client discharge pent-up anger through participation in large motor activities (e discount isoptin 240 mg. Physical exercise provides a safe and effective method for discharging pent-up tension purchase 40mg isoptin with amex. Explain to client the normal stages of grief and the behaviors associated with each stage. Help client to understand that feelings such as guilt and anger toward the lost entity are appropriate and acceptable during the grief process. Knowl- edge of the acceptability of the feelings associated with nor- mal grieving may help to relieve some of the guilt that these responses generate. With support and sensitivity, point out reality of the situation in areas where misrepresentations are expressed. Client must give up an idealized perception and be able to Adjustment Disorder ● 249 accept both positive and negative aspects about the painful life change before the grief process is complete. Knowledge of cultural influences specific to the client is im- portant before employing this technique. Help client solve problems as he or she attempts to determine methods for more adaptive coping with the experienced loss. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Encourage client to reach out for spiritual support during this time in whatever form is desirable to him or her. As- sess spiritual needs of client, and assist as necessary in the fulfillment of those needs. Spiritual support can enhance successful adaptation to painful life experiences for some individuals. Client is able to verbalize normal stages of grief process and behaviors associated with each stage. Client is able to identify own position within the grief pro- cess and express honest feelings related to the lost entity. Client will verbalize things he or she likes about self within (realistic time period). Client will exhibit increased feelings of self-worth as evi- denced by verbal expression of positive aspects about self, past accomplishments, and future prospects. Client will exhibit increased feelings of self-worth by setting realistic goals and trying to reach them, thereby demonstrat- ing a decrease in fear of failure. It is important for client to achieve something, so plan for activities in which success is likely. Promote understanding of your acceptance for him or her as a worthwhile human being. Unconditional positive regard and acceptance promote trust and increase client’s feelings of self-worth. Help client identify positive aspects of self and to develop plans for changing the characteristics he or she views as neg- ative. Individuals with low self-esteem often have difficulty recognizing their positive attributes. They may also lack problem-solving ability and require assistance to formulate a plan for implementing the desired changes. Encourage and support client in confronting the fear of failure by attending therapy activities and undertaking new tasks. Offer recognition of successful endeavors and positive reinforcement for attempts made. Enforce limit-setting in matter-of-fact manner, imposing previously established consequences for violations. Negative feedback can be ex- tremely threatening to a person with low self-esteem, pos- sibly aggravating the problem. Encourage independence in the performance of personal re- sponsibilities, as well as in decision-making related to own self-care. Help client increase level of self-awareness through criti- cal examination of feelings, attitudes, and behaviors. Help him or her to understand that it is perfectly acceptable for one’s attitudes and behaviors to differ from those of others as long as they do not become intrusive. As the client achieves self-awareness and self-acceptance, the need for judging the behavior of others will diminish. Client demonstrates ability to manage own self-care, make independent decisions, and use problem-solving skills. Client sets goals that are realistic and works to achieve those goals without evidence of fear of failure. Client will be able to interact with others on a one-to-one basis with no indication of discomfort. Client will voluntarily spend time with others in group ac- tivities demonstrating acceptable, age-appropriate behavior. Be honest; keep all promises; convey acceptance of person, separate from unac- ceptable behaviors (“It is not you, but your behavior, that is unacceptable. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Confront client and withdraw attention when interactions with others are manipulative or exploitative. Act as role model for client through appropriate interactions with him or her, other clients, and staff members. It is through these group interactions, with positive and negative feedback from his or her peers, that client will learn socially accept- able behavior. Client has formed and satisfactorily maintained one inter- personal relationship with another client. Client verbalizes reasons for inability to form close interper- sonal relationships with others in the past. Possible Etiologies (“related to”) Move from one environment to another [Losses involved with decision to move] Feelings of powerlessness Lack of adequate support system [Little or no preparation for the impending move] Impaired psychosocial health [status] Decreased [physical] health status Defining Characteristics (“evidenced by”) Anxiety Depression Loneliness Verbalizes unwillingness to move Sleep disturbance Increased physical symptoms Dependency Insecurity Withdrawal Anger; fear Goals/Objectives Short-term Goal Client will verbalize at least one positive aspect regarding re- location to new environment within (realistic time period). Encourage individual to discuss feelings (concerns, fears, anger) regarding relocation. Exploration of feelings with a trusted individual may help the individual perceive the situation more realistically and come to terms with the inevitable change. Ensure that the individual is involved in decision-making and problem-solving regarding the move. Taking responsibility for making choices regarding the relo- cation will increase feelings of control and decrease feelings of powerlessness. Anxiety associated with the opposed relocation may inter- fere with the individual’s ability to recognize anything posi- tive about it. Help the individual identify resources within the new com- munity from which assistance with various types of services may be obtained. Because of anxiety and depression, the in- dividual may not be able to identify these resources alone. Identify groups within the community that specialize in helping individuals adapt to relocation. Examples include Newcomers’ Club, Welcome Wagon International, senior citizens’ groups, and school and church organizations. These groups offer support from individuals who may have en- countered similar experiences. Adaptation may be enhanced by the reassurance, encouragement, and support of peers who exhibit positive adaptation to relocation stress. An individual who is experiencing com- plicated grieving over loss of previous residence may require therapy to achieve resolution of the problem.

For example isoptin 120 mg low cost, fined around its trim and what it does in a given the future of nursing is tied to Nightingale’s sense setting and at a given point in time order isoptin online from canada. Nor can nurs- of “calling 120mg isoptin free shipping,” guided by a deep sense of commitment ing’s trim define and clarify its larger professional and a covenantal ethic of human service order isoptin toronto, cherishing ethic and mission to society—its raison d’être for our phenomena, our subject matter, and those we the public. That is where nursing theory comes into play, and transpersonal caring theory offers another It is when we include caring and love way that both differs from and complements that in our work and in our life that we which has come to be known as “modern” nursing discover and affirm that nursing, like and conventional medical-nursing frameworks. Formation of a humanistic-altruistic system of work and in our life that we discover and affirm values. Development of a helping-trusting, human require transforming self and those we serve, in- caring relationship. Promotion and acceptance of the expression of we more publicly and professionally assert these positive and negative feelings. Provision for a supportive, protective, and/ process; to engage in artistry of caring-healing or corrective mental, physical, societal, and practices. Allowance for existential-phenomenological- learning experience that attends to unity of spiritual forces. Provision for a supportive, protective, and/or carative factors still hold, and indeed are used as the corrective mental, physical, societal, and spir- basis for some theory-guided practice models and itual environment becomes creating a healing research, what I am proposing here, as part of my environment at all levels (a physical and non- evolution and the evolution of these ideas and the physical, subtle environment of energy and theory itself, is to transpose the carative factors into consciousness, whereby wholeness, beauty, “clinical caritas processes. Assistance with gratification of human needs and emerging transpersonal caring theory. Allowance for existential-phenomenological- suggesting more open ways in which they can be spiritual forces becomes opening and attending considered. For example: to spiritual-mysterious and existential dimen- sions of one’s own life-death; soul care for self 1. Instillation of faith-hope becomes being au- evocation of love and caring are merged for a new thentically present and enabling and sustaining paradigm for this millennium. Such a perspective the deep belief system and subjective life world ironically places nursing within its most mature of self and one being cared for. Cultivation of sensitivity to one’s self and to model of nursing—yet to be actualized but await- others becomes cultivation of one’s own spir- ing its evolution within a caring-healing theory. Development of a helping-trusting, human Thus, I consider my work more a philosophical, caring relationship becomes developing and ethical, intellectual blueprint for nursing’s evolving sustaining a helping-trusting, authentic caring disciplinary/professional matrix, rather than a spe- relationship. Promotion and acceptance of the expression of with the original work at levels of concreteness or positive and negative feelings becomes being abstractness. The caring theory has been, and is still present to, and supportive of, the expression of being, used as a guide for educational curricula, positive and negative feelings as a connection clinical practice models, methods for research and with deeper spirit of self and the one being inquiry, and administrative directions for nursing cared for. It is also a critical start- to ontological development of the nurse’s human ing point for nursing’s existence, broad societal competencies and ways of being and becoming. Nevertheless, its use and critical in this model as “technological curing com- evolution is dependent upon “critical, reflective petencies” were in the conventional modern, practices that must be continuously questioned and Western nursing-medicine model, which is now critiqued in order to remain dynamic, flexible, and coming to an end. Transpersonal Caring Relationship The nurse attempts to enter into and stay within the The terms transpersonal and a transpersonal caring other’s frame of reference for connecting with the relationship are foundational to the work. But transpersonal also goes beyond the ate comfort measures, pain control, a sense of well- ego self and beyond the given moment, reaching to being, wholeness, or even a spiritual transcendence the deeper connections to spirit and with the of suffering. Thus, a transpersonal caring rela- complete, regardless of illness or disease (Watson, tionship moves beyond ego self and radiates to 1996, p. Assumptions of Transpersonal Caring Relationship Transpersonal caring seeks to connect with The nurse’s moral commitment, intentionality, and and embrace the spirit or soul of the other caritas consciousness is to protect, enhance, pro- through the processes of caring and heal- mote, and potentiate human dignity, wholeness, ing and being in authentic relation, in the and healing, wherein a person creates or cocreates moment. Transpersonal caring seeks to connect with and The nurse’s will and consciousness affirm the embrace the spirit or soul of the other through the subjective-spiritual significance of the person while processes of caring and healing and being in au- seeking to sustain caring in the midst of threat and thentic relation, in the moment. Such a transpersonal relation is influenced by This honors the I-Thou relationship versus an I-It the caring consciousness and intentionality of the relationship. Actions, words, be- uniqueness of self and other and the uniqueness of haviors, cognition, body language, feelings, intu- the moment, wherein the coming together is mu- ition, thought, senses, the energy field, and so on, tual and reciprocal, each fully embodied in the mo- all contribute to transpersonal caring connection. The moment of by releasing some of the disharmony, the blocked energy that interferes with the natural healing A caring moment involves an action and processes. For example: nurse’s own life history and previous experiences, which provide opportunities for focused studies, [W]e learn from one another how to be human the nurse having lived through or experienced var- by identifying ourselves with others, finding their ious human conditions and having imagined oth- dilemmas in ourselves. We learn to degree, the necessary knowledge and consciousness recognize ourselves in others... Other facilitators include per- The dynamic of transpersonal caring (healing) sonal- growth experiences such as psychotherapy, within a caring moment is manifest in a field of transpersonal psychology, meditation, bioenerget- consciousness. The transpersonal dimensions of a ics work, and other models for spiritual awakening. The role of conscious- notion of health professionals as wounded healers ness with respect to a holographic view of science is acknowledged as part of the necessary growth has been discussed in earlier writings (Watson, and compassion called forth within this theory/ 1992, p. A caring occasion occurs whenever the nurse and • The one caring and the one being cared for are another come together with their unique life histo- interconnected; the caring-healing process is ries and phenomenal fields in a human-to-human connected with the other human(s) and with transaction. It • The caring-healing-loving consciousness of the becomes transcendent, whereby experience and nurse is communicated to the one being cared perception take place, but the actual caring occa- for. The process goes beyond itself yet arises from through and transcends time and space and can aspects of itself that become part of the life history be dominant over physical dimensions. It transcends clarify where one may locate self within the time, space, and physicality. The Caring Model or Theory can be considered a • Are those involved “conscious” of their caring philosophical and moral/ethical foundation for caritas or noncaring consciousness and inten- professional nursing and is part of the central focus tionally in a given moment, at individual and for nursing at the disciplinary level. It offers to expanding their caring consciousness and a framework that embraces and intersects with art, actions to self, other, environment, nature, and science, humanities, spirituality, and new dimen- wider universe? However, to truly “get it,” one has to experience This work, in both its original and evolving it personally. The model is both an invitation and forms, seeks to develop caring as an ontological- an opportunity to interact with the ideas, epistemological foundation for a theoretical- experiment with and grow within the philosophy, philosophical-ethical framework for the profession and to live it out in one’s personal/professional life. Nursing caring theory-based activi- 2004), provide us with a chance to assess, critique, ties as guides to practice, education, and research and see where or how, or even if, we may locate have developed throughout the United States ourselves within a framework of caring science as a and other parts of the world. The caring model is basis for the emerging ideas in relation to our own consistently one of the nursing caring theories used “theories and philosophies of professional nursing as a guide. Nursing thus ironically is interacting with the caring model to transform now challenged to stand and mature within and/or improve practice? The it mean to be human, caring, healing, becoming, future already reveals that all health-care growing, transforming, and so on? For example, practitioners will need to work within a in the words of Teilhard de Chardin:“Are we hu- shared framework of caring relationships and mans having a spiritual experience, or are we human-environment field modalities, pay at- spiritual beings having a human experience? Participants were invited to explore Transpersonal However, nursing’s future holds promises of Human Caring Theory (Caring Theory), as taught caring and healing mysteries and models yet and modeled by Dr. Jean Watson, through experi- to unfold, as opportunities for offering com- ential interactions with caring-healing modalities. Nursing has a critical role to play Returning from the retreat to the preexisting in sustaining caring in humanity and making schedules, customs and habits of hospital routine new connections between caring, love, and was both daunting and exciting. Caring Theory, and not as a remote and abstract philosophical ideal; rather, we had experienced car- ing as the very core of our true selves, and it was the call that led us into health-care professions. Our experiences throughout the re- treat had accentuated caring as our core value. Caring Theory could not be restricted to a single Application of area of practice. Nursing within acute care inpatient hospital set- Theory of tings is practiced dependently, collaboratively, and independently (Bernardo, 1998). Bernardo de- scribes dependent practice as energy directed by Human Caring and requiring physician orders, collaborative prac- Terri Kaye Woodward tice as interdependent energy directed toward activities with other health-care professionals, and independent practice as “where the meaningful role and impact of nursing may evolve” (p. Transpersonal Caring Theory and the caring Although Bernardo’s description of inpatient nurs- model “can be read, taught, learned about, studied, ing captures the composite and fragmented role researched and even practiced: however, to truly ‘get it,’ one has to personally experience it—interact and grow within the philosophy and intention of 1 See Watson,J. This section of Model® integrating theory, evidence and advanced caring-healing the chapter provides a look into Transpersonal therapeutics for transforming professional practice. Watson’s clinical caritas of deep respect for humanity and all life, of wonder processes are listed, as well as an abbreviated ver- and awe of life’s mystery, and the interconnected- sion of her guidelines for cultivating caring-healing ness from mind-body-spirit unity into cosmic throughout the day (Watson, 2002). Gadow (1995) describes written in Caring Theory language, expresses our nursing as a lived world of interdependency and intention to all and reminds us that caring is the shared knowledge, rather than as a service pro- core of our praxis. Caring praxis within this lived world is a Second, a shallow bowl of smooth, rounded praxis that offers “a combination of action and re- river stones is located in a prominent position at flection... A sign posted by the stones iden- and a relationship with the wider community” tify them as “Caring-Healing Touch Stones” invit- (Penny & Warelow, 1999, p.

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