Neuroimaging studies have found some differences in brain structure between schizophrenic and normal patients dilantin 100 mg free shipping. In some people with schizophrenia purchase dilantin 100mg fast delivery, the cerebral ventricles (fluid-filled spaces in [19] the brain) are enlarged (Suddath purchase dilantin 100mg amex, Christison cheap dilantin 100 mg on-line, Torrey dilantin 100mg, Casanova, & Weinberger, 1990). People with schizophrenia also frequently show an overall loss of neurons in the cerebral cortex, and some show less activity in the frontal and temporal lobes, which are the areas of the brain involved in language, attention, and memory. This would explain the deterioration of functioning Attributed to Charles Stangor Saylor. Many researchers believe that schizophrenia is caused in part by excess dopamine, and this theory is supported by the fact that most of the drugs useful in treating schizophrenia inhibit [21] dopamine activity in the brain (Javitt & Laruelle, 2006). But recent evidence suggests that the role of neurotransmitters in schizophrenia is more complicated than was once believed. It also remains unclear whether observed differences in the neurotransmitter systems of people with schizophrenia cause the disease, or if they are the result of the disease itself or its treatment (Csernansky & Grace, [23] 1998). A genetic predisposition to developing schizophrenia does not always develop into the actual disorder. Even if a person has an identical twin with schizophrenia, he still has less than a 50% chance of getting it himself, and over 60% of all schizophrenic people have no first- or second- degree relatives with schizophrenia (Gottesman & Erlenmeyer-Kimling, 2001; Riley & Kendler, [24] 2005). One hypothesis is that schizophrenia is caused in part by disruptions to normal brain development in infancy that may be caused by poverty, malnutrition, and disease (Brown et al. Stress also increases the likelihood that a person will develop schizophrenic symptoms; onset and relapse of schizophrenia typically occur during periods of increased stress [26] (Walker, Mittal, & Tessner, 2008). However, it may be that people who develop schizophrenia are more vulnerable to stress than others and not necessarily that they experience [27] more stress than others (Walker, Mittal, & Tessner, 2008). Another social factor that has been found to be important in schizophrenia is the degree to which one or more of the patient‘s relatives is highly critical or highly emotional in their attitude toward Attributed to Charles Stangor Saylor. Hooley and Hiller (1998) found that schizophrenic patients who ended a stay in a hospital and returned to a family with high expressed emotion were three times more likely to relapse than patients who returned to a family with low expressed emotion. It may be that the families with high expressed emotion are a source of stress to the patient. Rather, there are a variety of biological and environmental risk factors that interact in a complex way to increase the likelihood that someone might develop schizophrenia. Is it better to keep patients in psychiatric facilities against their will, but where they can be observed and supported, or to allow them to live in the community, where they may commit violent crimes against themselves or others? Prevalence of neuroleptic-induced movement disorders in chronic schizophrenia patients. Antecedents, symptom progression, and long-term outcome of the deficit syndrome in schizophrenia. Anatomical abnormalities in the brains of monozygotic twins discordant for schizophrenia. Family and twin studies as a head start in defining prodomes and endophenotypes for hypothetical early interventions in schizophrenia. The neurodevelopmental basis of schizophrenia: Clinical clues from cerebro-craniofacial dysmorphogenesis, and the roots of a lifetime trajectory of disease. Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Stress and the hypothalamic pituitary adrenal axis in the developmental course of schizophrenia. Categorize the different types of personality disorders and differentiate antisocial personality disorder from borderline personality disorder. Outline the biological and environmental factors that may contribute to a person developing a personality disorder. Apersonality disorder is a disorder characterized by inflexible patterns of thinking, feeling, or relating to others that cause problems in personal, social, and work situations. Personality disorders tend to emerge during late childhood or adolescence and usually continue throughout [1] adulthood (Widiger, 2006). The disorders can be problematic for the people who have them, but they are less likely to bring people to a therapist for treatment than are Axis I disorders. They are categorized into three types: those characterized by odd or eccentric behavior, those characterized by dramatic or erratic behavior, and those characterized by anxious or inhibited behavior. Probably you know someone who seems a bit suspicious and paranoid, who feels that other people are always “ganging up on him,‖ and who really doesn‘t trust other people very much.

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Implications for practice ■ costs involve both financial and human aspects; human costs are subjective order dilantin 100 mg line, including debatable issues such as quality of life generic 100mg dilantin free shipping, but are fundamentally central to nursing values ■ medical outcome scoring systems are available safe 100mg dilantin, but predictive reliability for individuals is debated generic dilantin 100 mg, and so rationing by scoring systems is ethically questionable ■ post-discharge nursing visits/clinics can reduce the psychological cost of intensive care to ex-patients and identify areas of nursing practice that need development Summary This final chapter has revisited issues raised at the start of this book cheap 100mg dilantin with amex, namely: ■ What fundamentally are we doing for our patients? There are many possible answers to these questions; discussion in other chapters should have developed readers’ awareness of these issues in everyday practice. Attempts to equate financial costs with humanitarian (morbidity) costs may help nurses to justify the value of their nursing, but may also create the danger that—to adapt Oscar Wilde—we know the price of everything, but the value of nothing. Further reading As part of their continuing professional development, readers should understand the practice of their own clinical speciality within the provision of wider healthcare; sociological perspectives, such as Caldwell et al. Nursing has echoed the medical literature’s interest in wider economic issues; Endacott (1996) provides a useful nursing perspective. Answers The following are the answers to questions to be found in the Clinical Scenarios at the ends of the chapters indicated. Babinski’s sign normal flexor responses are replaced by extensor responses, big toe turns upwards; in adults this indicates upper motor neurone (pyramidal tract) pathology. Sengstarken tube) places direct pressure on bleeding points; thus internal bleeding is stopped in the same way that nurses use digital pressure to stop bleeding after arterial lines are removed. Calorie (Cal, C) amount of heat needed to raise one kilogram of water 1°C at atmospheric pressure (=large calorie, kilocalorie). Circadian rhythm affects various endogenous hormone levels, so that a disturbed Glossary 470 circadian rhythm results in various abnormal body responses (e. Fluids with high colloid osmotic pressures therefore assist return of extravascular fluid (oedema) into the bloodstream. FiO 2 fraction of inspired oxygen (expressed as a decimal fraction, so that FiO2 1. Frank-Starling law the force exerted during each heartbeat is directly proportional to the length or degree of myocardial fibre stretch; thus increasing fibre length (e. General Adaptive Syndrome a reaction to stressors that causes generalised physiological responses throughout the body; first described by Hans Selye (see Chapter 46). Glossary 471 hysteresis literally, the difference between two phenomena; in a medical context, it usually refers to lung differences between inspiration and expiration (pressure/volume curve), where passive elastic recoil allows greater volume in relation to airway pressure during expiration than during inspiration; thus manipulating I:E ratio also manipulates mean airway pressure. Krebs’ cycle (citric acid cycle) a chain of intracellular chemical reactions to metabolise fat for energy. Krebs’ cycle is efficient at energy (adenosine triphosphate) production, but produces metabolic wastes (acids, ketones, carbon dioxide, water); see Chapter 9. At rest, people (and animals) take sigh breaths, which ventilate the lung bases, so helping to prevent atelectasis and infection; like most breaths, this usually occurs spontaneously and unconsciously. The benefits of physiological sigh breaths encouraged manufacturers to incorporate them into artificial ventilators, but sigh breaths during artificial ventilation do not appear to provide any benefits (see Chapter 4). Where artificial technologies replicate capillary function, such as the ‘artificial kidneys’ used for haemofiltration, excessive pressure may rupture the necessarily delicate membrane. As the surface area of the filter becomes progressively engorged with clots, filtrate is forced through a smaller area, increasing transmembrane pressure. Therefore measuring the transmembrane pressure should identify impending rupture of the artificial kidney. Stopping filters before maximum transmembrane pressure is reached enables blood in the circuit to be safely returned to Glossary 473 the patient. V/Q ratio (alveolar) ventilation to (pulmonary capillary) perfusion ratio; normal V/Q=0. Desautels (eds) Mechanical Ventilation , Edinburgh: Churchill Livingstone: 307–26. Price (eds) Managing the Nursing Priorities in Intensive Care , Dinton: Quay Books: 134–70. Withington (eds) Textbook of Intensive Care London: Chapman & Hall: 577–83 Asensio, J. Pesce (eds) Clinical Chemistry: Theory, Analysis, Correction St Louis: Mosby: 213–49. References 478 ——(1996) ‘Toward a theory regarding the pathogenesis of the septic inflammatory response syndrome: what we do know and do not know about cytokine regulation’, Critical Care Medicine 24(1): 163–72.

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Neuman received honorary client system and presents nursing as a field prima- doctorates from Grand Valley State University in rily concerned with defining appropriate nursing Allendale generic 100mg dilantin with amex, Michigan 100 mg dilantin fast delivery, in 1998 order dilantin 100mg with amex, and from Neuman actions in stressor-related situations or in possible College in Aston dilantin 100mg with mastercard, Pennsylvania buy discount dilantin 100mg on-line, in 1992. The client and Neuman is an honorary fellow in the American environment may be positively or negatively af- Academy of Nursing. There is a tendency within any system to maintain a steady state or balance among the various disruptive forces operating within or The Neuman Systems Model upon it. Neuman has identified these forces as stressors and suggests that possible reactions and The Neuman Systems Model provides a comprehen- actual reactions with identifiable signs or symp- sive, flexible, holistic, and systems-based perspective toms may be mitigated through appropriate early for nursing. Neuman (1995) defined conceptual model concepts, whereas other proposi- tions state the relationships among conceptual model concepts in a general manner. In Fawcett’s Neuman (1995) defined system as a perva- (1995a) analysis of the Neuman Systems Model, sive order that holds together its parts. With this definition in mind, she writes that believes that Neuman’s primary, secondary, and nursing can be readily conceptualized as a complete tertiary preventions provide the required linkages whole, with identifiable smaller wholes or parts. The fol- The complete whole structure is maintained by in- lowing propositions describe, define, and connect terrelationships among identifiable smaller wholes concepts essential to understanding the conceptual or parts through regulations that evolve out of the model that is presented in the next section of this dynamics of the open system. Although each individual client or group as a gentropy or evolution as a system absorbs energy client system is unique, each system is a com- to increase its organization, complexity, and devel- posite of common known factors or innate opment when it moves toward a steady or wellness characteristics within a normal, given range of state. An open system of energy exchange is never response contained within a basic structure. Many known, unknown, and universal envi- toward differentiation and elaboration for further ronmental stressors exist. Tertiary prevention relates to the adaptive pro- interrelationships of client variables—physio- cesses taking place as reconstitution begins and logical, psychological, sociocultural, develop- maintenance factors move the client back in a mental, and spiritual—at any point in time can circular manner toward primary prevention. The client as a system is in a dynamic, constant by the flexible line of defense against possible energy exchange with the environment reaction to a single stressor or a combination of (Neuman, 1995, pp. The conceptual model was resents change over time through coping with developed to explain the client-client system as an diverse stress encounters. When the cushioning, accordion-like effect of tive relationships that exist between the client and the flexible line of defense is no longer capable the caregiver in Neuman’s model. Neuman now of protecting the client-client system against an believes the model can be equally well applied to environmental stressor, the stressor breaks a group, larger community, or social issue and is ap- through the normal line of defense. The inter- propriate for nursing and other health disciplines relationships of variables—physiological, psy- (Neuman, 1995). The client, whether in a state of wellness or client system, environment, and nursing aspects of illness, is a dynamic composite of the interre- the nursing domain. Wellness is on a continuum of avail- able energy to support the system in an optimal The structure of the client-client system is illus- state of system stability. Implicit within each client system are internal sists of the flexible line of defense, the normal line resistance factors know as lines of resistance, of defense, lines of resistance, and the basic struc- which function to stabilize and return the client ture energy resources (shown at the core of the to the usual wellness state (normal line of de- concentric circles in Figure 18-2). Five client vari- fense) or possibly to a higher level of stability ables—physiological, psychological, sociocultural, following an environmental stressor reaction. Primary prevention relates to general knowl- sidered simultaneously in each concentric circle edge that is applied in client assessment and that makes up the client-client system (Neuman, intervention in identification and reduction or 1995). The goal of health Stressors must penetrate the flexible line of defense promotion is included in primary prevention. Neuman described this line of de- ogy following a reaction to stressors, appropri- fense as an accordion-like mechanism that acts like ate ranking of intervention priorities, and a protective buffer system to help prevent stressor treatment to reduce their noxious effects. A holistic view of a dynamic open client-client system interacting with environmental stressors, along with client and caregiver collaborative participation in promoting an optimum state of wellness. What are the effects of short- Basic structure term loss of sleep, poor nutrition, or dehydration Basic factors common to all organisms, i. Will these sit- Normal temperature uations increase the possibility for stressor penetra- range tion? The answer is that the possibility for stressor Genetic structure Response pattern penetration may be increased. The actual response Organ strength or depends upon the accordion-like mechanism pre- weakness viously described, along with the other compo- Ego structure Knowns or commonalities nents of the client system. Normal Line of Defense n The normal line of defense represents what the client has become over time, or the usual state of The normal line of defense represents what the client has become over time, or the usual state of wellness. The nurse should determine the client’s usual level of wellness in order to recognize a change in the level of wellness. The normal line of defense is considered dynamic by Neuman, because it can expand or contract over time. Neuman also con- developmental, and spiritual variables occur siders the normal line of defense dynamic because and are considered simultaneously in each client concentric circle.

An adequate database is necessary for the development of an effective teaching plan order dilantin 100mg amex. Teaching will be ineffective if presented at a level or by a method inappropriate to the client’s ability to learn 100mg dilantin visa. Provide information regarding healthful strate- gies for activities of daily living as well as about harmful effects of substance abuse on the body buy cheap dilantin 100 mg line. Include suggestions for community resources to assist client when adaptability is impaired discount dilantin 100 mg on line. Input from individuals who are directly involved in the potential change increases the likelihood of a positive outcome buy cheap dilantin 100mg. Implement teaching plan at a time that facilitates, and in a place that is conducive to, optimal learning (e. Provide activities for client and significant others in which to actively participate during the learning exercise. Ask client and significant others to demonstrate knowledge gained by verbalizing information regarding positive self- care practices. Verbalization of knowledge gained is a mea- surable method of evaluating the teaching experience. Provide positive feedback for participation, as well as for accurate demonstration of knowledge gained. Positive feed- back enhances self-esteem and encourages repetition of desirable behaviors. Client is able to verbalize available community resources for obtaining knowledge about and help with deficits related to health care. Incest is the occurrence of sexual contacts or interaction between, or sexual exploitation of, close relatives, or between participants who are related to each other by a kinship bond that is regarded as a pro- hibition to sexual relations (e. Neglect of a Child Physical neglect of a child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. Emotional neglect refers to a chronic failure by the parent or care- taker to provide the child with the hope, love, and support nec- essary for the development of a sound, healthy personality. Physical Abuse of an Adult Physical abuse of an adult may be defined as behavior used with the intent to cause harm and to establish power and con- trol over another person. It may include slaps, punches, biting, hair-pulling, choking, kicking, stabbing or shooting, or forcible restraint. Sexual Abuse of an Adult Sexual abuse of an adult may be defined as the expression of power and dominance by means of sexual violence, most com- monly by men over women, although men may also be victims of sexual assault. Sexual assault is identified by the use of force and executed against the person’s will. Various components of the neurological system in both humans and animals have been implicated in both the facilitation and inhibition of aggressive impulses. Areas of the brain that may be in- volved include the temporal lobe, the limbic system, and the amygdaloid nucleus (Tardiff, 2003). Studies show that various neurotransmitters—in particular norepinephrine, dopa- mine, and serotonin—may play a role in the facilitation and inhibition of aggressive impulses (Hollander, Berlin, & Stein, 2008). Some studies have implicated heredity as a component in the predisposition to aggressive behav- ior. The psychodynamic theorists imply that unmet needs for satisfaction and security re- sult in an underdeveloped ego and a weak superego. It is thought that when frustration occurs, aggression and vio- lence supply this individual with a dose of power and pres- tige that boosts the self-image and validates a significance to his or her life that is lacking. The immature ego cannot prevent dominant id behaviors from occurring, and the weak superego is unable to produce feelings of guilt. This theory postulates that aggressive and violent behaviors are learned from prestigious and influential role models. Individuals who were abused as children or whose parents disciplined with physical pun- ishment are more likely to behave in a violent manner as adults (Tardiff, 2003). Social scientists believe that aggres- sive behavior is primarily a product of one’s culture and social structure. Societal influences may contribute to violence when individuals believe that their needs and desires cannot be met through conventional means, and they resort to delinquent behaviors in an effort to obtain desired ends. They may present with different colors of bluish-purple to yellowish-green (indicating various stages of healing). Rashes or itching in the genital area; scratching the area a great deal or fidgeting when seated.

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