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By I. Xardas. Cheyney University of Pennsylvania.

Clearly purchase 5mg buspirone overnight delivery, focus of care (client system) and/or focus of health these applications buy discount buspirone on line, and others discount generic buspirone uk, show how the problem (phenomenon of concern) buspirone 5mg with mastercard. The focus of complexity of King’s framework and midrange the- care, or interest, can be an individual (personal sys- ory increases its usefulness for nursing (refer to tem) or group (interpersonal or social system). Thus, application of King’s work, across client sys- tems, would be divided into the three systems iden- Client Systems tified within King’s Interacting Systems Framework A major strength of King’s work is that it can (1981): personal (the individual), interpersonal be used with virtually all client populations. Frey addition, applications proposed the Theory of and Norris (1997) used both the Interacting Sys- Goal Attainment as the practice model for case tems Framework and Theory of Goal Attain- management (Hampton, 1994; Tritsch, 1996). The earliest 1995a) and revised into a Theory of Group Power applications involved the use of the framework and within Organizations (2003). Educational settings, theory to guide continuing education (Brown & also considered as social systems, have also been Lee, 1980) and nursing curricula (Daubenmire, the focus of application of King’s work (Bello, 1989; Gulitz & King, 1988). Table 16–9 sum- marizes applications related to clients’ phenomena Phenomena of Concern to Clients of concern; the table also groups these applications, Within King’s work, it is critically important for the primarily identified by disease or medical diagno- nurse to focus on, and address, the phenomenon of sis, as illness management. Without this emphasis on the Health is one area that certainly binds clients client’s perspective, mutual goal-setting cannot and nurses. Hence, a client’s phenomena of concern was end point, or outcome, of nursing care and selected as neutral terminology that clearly demon- something to which clients aspire. In addition, Frey applications, tends to support the goal of improved (1996) expanded her research to include risky health directly and/or indirectly, as the result of the behaviors. Health status is explic- As stated previously, diseases or diagnoses are itly the outcome of concern in practice applica- often identified as the focus for the application of tions by Smith (1988). For example, Kohler (1988) conducted research with patients with broncho- focused on increased morale and satisfaction, and pneumonia, while patients with end-stage renal DeHowitt (1992) studied well-being. In Health promotion has also been an emphasis for addition, clients with chronic inflammatory bowel the application of King’s ideas. The experience of parenting was studied by concerns have also been the focus of work, using Norris and Hoyer (1993), and health behaviors King’s conceptualizations (Murray & Baier, 1996; were Hanna’s (1995) focus of study. Clients’ concerns ranged from King (1981) stated that individuals act to main- psychotic symptoms (Kemppainen, 1990) to fami- tain their own health. Although not explicitly lies experiencing chronic mental illness (Doornbos, stated, the converse is probably true as well: 2002) to clients in short-term group psychotherapy Individuals often do things that are not good for (Laben, Sneed, & Seidel, 1995). Accordingly, it is not surprising that eates applications related to clients’ phenomena the Interacting Systems Framework and related of concern. Frey (1997), Frey and Denyes (1989), and Frey and Fox Multicultural applications of King’s Interact- (1990) looked at both health behaviors and illness ing Systems Framework and related theories are management behaviors in several groups of chil- many. King’s framework and theory for transcultural Applications of the framework and related theories nursing. Spratlen (1976) drew heavily from King’s have been documented in the following countries framework and theory to integrate ethnic cultural beyond the United States: Canada (Coker et al. Key Sugimori, 1992), Portugal (Moreira & Arajo, 2002; elements derived from King’s work were the focus Viera & Rossi, 2000), and Sweden (Rooke, 1995a, on perceptions and communication patterns that 1995b). In Japan, a culture very different from the motivate action, reaction, interaction, and transac- United States with regard to communication style, tion. Rooda (1992) derived propositions from the Kameoka (1995) used the classification system of midrange Theory of Goal Attainment as the frame- nurse-patient interactions identified within the work for a conceptual model for multicultural Theory of Goal Attainment (King, 1981) to analyze nursing. In addition to research Cultural relevance has also been demonstrated and publications regarding the application of in reviews by Frey, Rooke, Sieloff, Messmer, and King’s work to nursing practice internationally, Kameoka (1995) and Husting (1997). King have been Husting identified that cultural issues were implicit translated into other languages, including Japanese variables throughout King’s framework, particular (King, 1976, 1985; Kobayashi, 1970). Therefore, attention was given to the concept of health, which, perception and the influence of culture on percep- according to King (1990), acquires meaning from tion were identified as strengths of King’s theory. Table 16–10 lists applications of King’s work in Undoubtedly, the strongest evidence for the countries outside the United States. The theory and conceptual model also can apply in various situations relevant to nursing work and Work Settings administration. An additional source of division within the nursing profession is the work sites where nursing is prac- Nursing Specialties ticed and care is delivered. As the delivery of health care moves from the more traditional site of the A topic that frequently divides nurses is their area acute care hospital to community-based agencies of specialty. However, by using a consistent frame- and clients’ homes, it is important to highlight work across specialties, nurses would be able to commonalities across these settings, and it is im- focus more clearly on their commonalities, rather portant to identify that King’s framework and than highlighting their differences. A review of the midrange Theory of Goal Attainment continue to literature clearly demonstrates that Dr. King’s framework and related theories have application within a variety of nursing specialties (see Table Although many applications tend to be 16–11). This application is evident whether one is with nurses and clients in traditional reviewing a “traditional” specialty, such as medical- settings, successful applications have surgical nursing (Gill et al. Two specific ex- be with nurses and clients in traditional settings, amples of this include the application of King’s successful applications have been shown across work to case management (Hampton, 1994; Sowell other, including newer and nontraditional, settings. Both case management and & Rasi, 1990; Lockhart, 2000) to nursing homes managed care incorporate multiple disciplines as (Zurakowski, 2000), King’s framework and related they work to improve the overall quality and cost theories provide a foundation on which nurses can efficiency of the health care provided. Table 16–12 lists cations also address the continuum of care, a prior- applications within a variety of nursing work ity in today’s health-care environment. This use of knowledge across disciplines occurs frequently and can be very ap- Obviously, new nursing knowledge has resulted propriate if both disciplines’ perspectives are simi- from applications of King’s framework and theory. Second, the nursing rules of What is evidence-based practice and how will evidence must include heavier weight for research evidence-based nursing practice evolve? Titler been assimilated and accepted as core beliefs of the (1998), a nurse, defines evidence-based practice as discipline. In addition, King’s concept of perception (1981) Research conducted with a King theoretical base lends itself well to the definition of client out- is well positioned for application by nurse care- comes. Johnson and Maas (1997) define a nursing- givers, nurse administrators (Sieloff, 2003), and sensitive client outcome as “a measurable client or client-consumers (Killeen, 1996) as part of an family caregiver state, behavior, or perception that evolving definition of evidence-based nursing is conceptualized as a variable and is largely influ- practice. For example, King (1971) addressed client enced and sensitive to nursing interventions” preference, a possible part of an evidence-based (p. In an update nursing knowledge requires the use of client out- of the concept of satisfaction, King submits that come measurement. The use of standardized client satisfaction is a subset of her central concept of outcomes as study variables increases the ease with perceptions (Killeen, 1996). The evaluation component of the nursing process con- Both managed care and increasing use of technol- sistently refers back to the original goal state- ogy have challenged existing conceptual frame- ment(s). Standardized terms for diagnoses, inter- that King’s concepts have evolved within this ventions, and outcomes potentially improve com- changing health-care climate. Biegen and Tripp-Reimer (1997) sug- King (1981) has always promoted cooperation and gested middle-range theories be constructed from collaboration among disciplines. Alternatively, King’s terpersonal, and social systems need to include an framework and theory may be used as a theoretical expanded conceptualization of King’s concept of basis for these phenomena and may assist in knowl- goal-setting. Personal and professional goal-setting, edge development in nursing in the future. In addition, the variety of practice ap- able goals; solicit input for client care planning; re- plications evident in the literature clearly vise client care plan, as necessary; discuss progress attest to the complexity of King’s work. As re- toward goals; and provide data to facilitate evalua- searchers continue to integrate King’s theory tion of client care plan” (p. Specifically, she recom- References mends using her concepts of self, role, power, au- thority, decisions, time, space, communication, and Alligood, M. King’s evaluate the use of King’s concepts, and possibly, interacting systems and empathy. King’s theory for nurs- tions now occur without visual perceptions in the ing: Explication and evaluation. Imogene King’s theory as the foundation An essential component in the analysis of for the set of a teaching-learning process with undergrauation conceptual frameworks and theories is the [sic] students [Portuguese]. Theory-based practice in the characteristics of scope, usefulness, and com- emergency department. Consumer centric advocacy: Its connection to nursing frame- more specific in terms of the nature and works. The perception and judge- King fully intended her Interacting ment of senior baccalaureate student nurses in clinical deci- Systems Framework for nursing to be useful sion making.

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In a further study order buspirone 10 mg overnight delivery, community nurses were given descriptions of either a heart attack patient who had changed their health-related behaviour following a routine health check (healthy behaviour condi- tion) or a patient who had not (unhealthy behaviour condition) (Ogden and Knight 1995) order 5 mg buspirone overnight delivery. The results indicated that the nurses rated the patient in the unhealthy behaviour condition as less likely to follow advice order buspirone from india, more responsible for their condition and rated the heart attack as more preventable generic buspirone 5mg without prescription. In terms of the wider effects of screen- ing programmes, it is possible that the existence of such programmes encourages society to see illnesses as preventable and the responsibility of the individual, which may lead to victim blaming of those individuals who still develop these illnesses. This may be relevant to illnesses such as coronary heart disease, cervical cancer and breast cancer, which have established screening programmes. In the future, it may also be relevant to genetic disorders, which could have been eradicated by terminations. Screening in the form of secondary prevention involves the professional in both detection and intervention and places the responsibility for change with the doctor. The backlash against screening could, therefore, be analysed as a protest against professional power and paternalistic intervention. Recent emphasis on the psychological consequences of screening could be seen as ammunition for this movement, and the negative con- sequences of population surveillance as a useful tool to burst the ‘screening bubble’. Within this framework, the backlash is a statement of individualism and personal power. The backlash may reflect, however, a shift in medical perspective – a shift from ‘doctor help’ to ‘self-help’. In 1991, the British Government published the Health of the Nation document, which set targets for the reduction of preventable causes of mortality and morbidity (DoH 1991). This document no longer emphasized the process of secondary prevention – and therefore implicitly that of professional intervention – but illustrated a shift towards primary prevention, health promotion and ‘self-help’. During recent years there has been a shift towards self-help and health promotion, reflected by the preoccupation with diet, smoking, exercise and self-examination. Prevention and cure are no longer the result of professional intervention but come from the individual – patients are becoming their own doctors. Specific criteria have been developed to facilitate the screening process and research has been carried out to evaluate means to increase patient uptake of screening programmes. These have concerned the ethics of screening, its cost-effectiveness and its possible psychological consequences. Although screening programmes are still being developed and regarded as an important facet of health, there has been a recent shift from a system of ‘doctor help’ to ‘self-help’, which is reflected in the growing interest in health beliefs and health behaviour and the process of health promotion. However, it often does not challenge some of the biomedical approaches to ‘a successful outcome’. Perhaps promoting uptake implicitly accepts the biomedical belief that screening is beneficial. It is often assumed that changes in theoretical perspective reflect greater knowledge about how individuals work and an improved understanding of health and illness. Therefore, within this perspective, a shift in focus towards an examination of the potential negative consequences of screening can be understood as a better understanding of ways to promote health. However, perhaps the ‘backlash’ against screening also reflects a different (not necessarily better) way of seeing individuals – a shift from individuals who require expert help from professionals towards a belief that individuals should help themselves. This paper provides a comprehensive overview of the literature on screening and examines the contribution of psychological, service provision and demo- graphic factors. This comprehensive review examines the research to date on the impact of receiving either a positive or negative test result in terms of cognitive, emotional and behavioural outcomes. It then describes the concept of appraisal and Lazarus’s transactional model of stress which emphasizes psychology as central to eliciting a stress response. The chapter then describes the physiological model of stress and explores the impact of stress on changes in physiological factors such as arousal and cortisol production. Finally, it describes how stress has been measured both in the laboratory and in a more naturalistic setting and compares physiological and self- report measurement approaches. A layperson may define stress in terms of pressure, tension, unpleasant external forces or an emotional response. Contemporary definitions of stress regard the external environmental stress as a stressor (e. Researchers have also differentiated between stress that is harmful and damaging (distress) and stress that is positive and beneficial (eustress). In addition, researchers differentiate between acute stress such as an exam or having to give a public talk and chronic stress such as job stress and poverty. The most commonly used definition of stress was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of ‘person environment fit’. If a person is faced with a potentially difficult stressor such as an exam or having to give a public talk the degree of stress they experience is determined first by their appraisal of the event (‘is it stressful? A good person environment fit results in no or low stress and a poor fit results in higher stress. Cannon’s fight or flight model One of the earliest models of stress was developed by Cannon (1932). This was called the fight or flight model of stress, which suggested that external threats elicited the fight or flight response involving an increased activity rate and increased arousal. He suggested that these physiological changes enabled the individual to either escape from the source of stress or fight. Within Cannon’s model, stress was defined as a response to external stressors, which was predominantly seen as physiological. Cannon considered stress to be an adaptive response as it enabled the individual to manage a stressful event. However, he also recognized that prolonged stress could result in medical problems. The initial stage was called the ‘alarm’ stage, which described an increase in activity, and occurred immediately the individual was exposed to a stressful situation. The second stage was called ‘resistance’, which involved coping and attempts to reverse the effects of the alarm stage. They there- fore did not address the issue of individual variability and psychological factors were given only a minimal role. For example, whilst an exam could be seen as stressful for one person it might be seen as an opportunity to shine to another. This response is seen as non specific in that the changes in physiology are the same regardless of the nature of the stressor. This is reflected in the use of the term ‘arousal’ which has been criticized by more recent researchers. Therefore, these two models described individuals as passive and as responding automatically to their external world. Life events theory In an attempt to depart from both Selye’s and Cannon’s models of stress, which emphasized physiological changes, the life events theory was developed to examine stress and stress-related changes as a response to life experiences. These ranged in supposed objective severity from events such as ‘death of a spouse’, ‘death of a close family member’ and ‘jail term’ to more moderate events such as ‘son or daughter leaving home’ and ‘pregnancy’ to minor events such as ‘vacation’, ‘change in eating habits’, ‘change in sleeping habits’ and ‘change in number of family get-togethers’. However, this obviously crude method of measurement was later replaced by a variety of others, including a weighting system whereby each potential life event was weighted by a panel creating a degree of differentiation between the different life experiences. The individual’s own rating of the event is important It has been argued by many researchers that life experiences should not be seen as either objectively stressful or benign, but that this interpretation of the event should be left to the individual. For example, a divorce for one individual may be regarded as extremely upsetting, whereas for another it may be a relief from an unpleasant situation. They reported that a useful means of assessing the potential impact of life events is to evaluate the individual’s own ratings of the life experience in terms of (1) the desirability of the event (was the event regarded as positive or negative); (2) how much control they had over the event (was the outcome of the event determined by the individual or others); and (3) the degree of required adjustment following the event. This methodology would enable the individual’s own evaluation of the events to be taken into consideration. The problem of retrospective assessment Most ratings of life experiences or life events are completed retrospectively, at the time when the individual has become ill or has come into contact with the health profession. This has obvious implications for understanding the causal link between life events and subsequent stress and stress- related illnesses. For example, if an individual has developed cancer and is asked to rate their life experiences over the last year, their present state of mind will influence their recollection of that year. This effect may result in the individual over-reporting negative events and under-reporting positive events if they are searching for a psychosocial cause of their illness (‘I have developed cancer because my husband divorced me and I was sacked at work’).

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The complex dissociation of oxygen has been discussed in this chapter; the dissociation curve will be referred to in some later chapters to help nurses apply its principles to bedside care generic 10 mg buspirone with amex. Although carbon dioxide is carried through three mechanisms cheap 5 mg buspirone otc, its dissociation is relatively linear and simple generic 10mg buspirone fast delivery. Blood gas analysis is widely used to assess both respiratory and metabolic function order buspirone 10 mg without a prescription. Non-invasive and continuous display technology may replace intermittent arterial sampling, but components measured are likely to remain, and so have been described. Nurses can valuably develop their skills with blood gas analysis by working through samples from practice, remembering to apply information within the context of the whole patient. Articles on haemoglobinopathies appear periodically in nursing journals (Thomas & Westerdale 1997); further information can be obtained from the support groups mentioned above. This chapter begins with a discussion of acid-base balance, goes on to suggest briefly good practice for taking arterial blood gas samples, and then discusses other results commonly found in blood gas analysis. Like many other aspects of practice, the technology for blood gas analysis varies, as does the data used between units. Acid-base definitions An acid is a substance capable of providing hydrogen ions; a base is capable of accepting hydrogen ions. Acid-base balance, therefore, is the power of hydrogen ions (pH) measured in moles per litre (‘power’ used in the mathematical sense, for the negative logarithm). The power of hydrogen ions can be controlled (balanced) either through buffering or exchange. Hydrogen is a positively charged ion (cation) which can be buffered by negatively charged ions (anion) such as bicarbonate. Hydrogen may move into another body compartment, either through pressure gradient differentials or in exchange for similarly charged ions. The only other significant cations in the human body are sodium and potassium, while the only significant anions are chloride and bicarbonate. Intensive care nursing 166 pH measurement Hydrogen ion concentrations in body fluids are about one million times less than concentrations of other ions (Hornbein 1994). Despite these very small concentrations, hydrogen ions are highly reactive, with small changes in concentration creating significant changes in enzyme activity (Hornbein 1994) and oxygen carriage (the Bohr effect—see Chapter 18). With plasma concentrations being so small, ions are measured by a negative logarithm. Thus, the log to the base 10 represents multiples of 10 by a power: Increasing one figure in the power represents a tenfold increase in the actual number. Negative logarithms use the same principle to manage very small numbers, so that: Acid-base balance and arterial blood gases 167 Normal plasma concentrations of 0. While the pH scale enables concentrations of huge ranges within confined limits of 0–14 (absolute acid to absolute alkaline), small alterations in pH can significantly alter hydrogen ion concentrations. With homeostasis, arterial pH maintains a bicarbonate to carbon dioxide ratio of 20:1 (Prencipe & Brenna, undated). Because minute concentrations of hydrogen ions have such profound effects, blood pH needs to be maintained within very narrow ranges—usually given as 7. Blood below this range is therefore termed ‘acidotic’, even though chemically it remains alkaline until reaching a pH of 7. Metabolism produces about 40–80 nmol of hydrogen each day (Marshall 1995), creating a concentration gradient between intracellular (highest) levels and plasma. Although chemically useful, extremes of human life have narrow pH ranges: Marieb (1995) cites 7. Homeostasis, therefore, aims to maintain levels within physiological levels of about 7. Acid-base balance is controlled through three mechanisms: ■ respiratory ■ renal ■ chemical buffering Respiratory control In the lungs, carbonic acid, being unstable, dissociates into water and carbon dioxide: Thus, partial pressure of carbon dioxide in plasma indicates carbonic acid level, and carbon dioxide is therefore considered a potential acid (lacking hydrogen ions, it is not really an acid). Intensive care nursing 168 The body produces 15,000–20,000 mmol of carbon dioxide each day (Coleman & Houston 1998). Hypercapnia stimulates medullary chemoreceptors, thus stimulating the respiratory centre to increase rate and depth of breaths, which removes essential components of carbonic acid. Although respiration cannot remove hydrogen ions, it can inhibit carbonic acid formation, so restoring homeostasis. Respiratory acidosis is caused either by lung disease (impairing carbon dioxide exchange) or hypoventilation. Respiratory alkalosis is caused by hyperventilation (high rate, tidal/minute volume). Respiratory response to acidosis occurs within three minutes of imbalance, exerting up to double the effect of combined chemical buffers (Marieb 1995). Renal control The kidneys actively contribute to acid-base balance in two ways: ■ hydrogen ion excretion ■ chemical buffering (producing and reabsorbing filtered bicarbonate and phosphate) and passively remove water (the remaining product of carbonic acid dissociation following respiratory removal of carbon dioxide). Although respiration controls carbonic acid, hydrogen ions can only be removed from the body by the kidneys, where they are actively exchanged for other cations, primarily sodium. Since potassium competes with hydrogen for sodium exchange, hyperkalaemia competes with acidosis for clearance of excess cations. The normal renal excretion of hydrogen ions is 30–70 mmol each day (Raftery 1997), although levels can reach 300 mmol per day within 7–10 days (Worthley 1997). This enables metabolic (renal) compensation for prolonged respiratory acidosis (e. Tubular selective reabsorption preserves most bicarbonate ions; the kidney also generates bicarbonate ions, so that renal failure can cause potentially profound metabolic acidoses. Chemical buffers respond rapidly, within seconds, balancing hydrogen ions by binding acids to bases, but do not eliminate acids from the body. The three main chemical buffers in blood are bicarbonate, phosphate and plasma proteins. Bicarbonate is the major chemical buffer of extracellular fluid, responsible for one- half of all chemical buffering (Coleman & Houston 1998). Bicarbonate combines with hydrogen to produce carbonic acid: Carbonic acid, the main acid in blood, is weak, readily dissociating into carbon dioxide and water (see Chapter 18). Therefore high serum bicarbonate can result in hypercarbia; carbon dioxide diffusing into intracellular fluid and across the blood-brain barrier may lead to intracellular acidosis and respiratory acidosis, although supporting evidence for these theories is lacking (Deakin 1997). Bicarbonate is reabsorbed and produced by the kidneys, and so bicarbonate mediation of acid-base balance relies on normal renal function (Coleman & Houston 1998). The body produces about 20,000 mmol of carbonic acid each day (Prencipe & Brenna, undated), making this a very efficient medium for acid-base balance. Plasma phosphate concentrations are low, but phosphate is the main urinary and interstitial buffer. Plasma and intracellular proteins: most chemical buffering occurs intracellularly. Histidine (in haemoglobin) is the main chemical buffer among plasma proteins, dissociating more readily from oxygen-poor haemoglobin. The respiratory centre is driven by hypercapnia, acidaemia or hypoxia, and so normal or slightly raised carbon dioxide levels are needed to create the respiratory drive for weaning, while acidaemia shifts the oxygen dissociation curve to the right, favouring unloading of oxygen from haemoglobin; but hypercapnia may create unwanted respiratory drive before weaning is appropriate. Acidosis has a negative effect on cardiac and other muscle conduction, and affects enzyme activity. Bicarbonate infusions (to reverse acidosis) can cause many problems; this is summarised by Mizock and Falk (1992): ■ leftward shift of dissociation curve from alkalinisation (theoretically) impairs oxygen dissociation ■ potential hyperosmolality/congestive cardiac failure from high sodium load ■ metabolic alkalosis if infusion volume is excessive ■ electrolyte imbalance (hypokalaemia, hypocalcaemia) impairing myocardial function ■ reflex vasodilation and hypotension ■ stimulation of glycolysis, producing further carbon dioxide and metabolic acidosis ■ myocardial depression Bicarbonate infusions are now usually given later (e. Acidosis is a symptom, not a disease; underlying pathologies should remain the focus of treatment. Oxygen delivery to peripheries should be optimised, without increasing cell metabolism; the use of large amounts of vasodilators and volume expanders to achieve this will probably necessitate cardiac output studies and monitoring. Acid-base balance and arterial blood gases 171 Tonometry Gastric (intramucosal) pH (pHi) is a good indicator of acidaemia, due to high blood flow to the gut (Fiddian-Green 1995; Bakker 1996). However, intramucosal bicarbonate may give a poor reflection of arterial levels, especially in hypoperfused patients (Gomersall & Oh 1997). With prolonged severe pathological processes, tonometry has some value, but it is not currently widely used for routine monitoring of acidaemia. Syringes using wet heparin (whether prepared in-house or purchased commercially) may cause dilutional inaccuracies, syringe lumens should be coated with heparin, then excess expelled, leaving only enough heparin to fill the hub of the syringe (Gosling 1995; Beaumont 1997)—0. If over one-tenth of the sample is heparin, carbon dioxide and bicarbonate readings will be significantly reduced (Hutchison et al.

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