Patient Care Plan Once a nursing diagnosis is reached order 30 pills rumalaya forte fast delivery muscle relaxant norflex, a care plan is developed that describes how the healthcare team will address the patient’s problems buy rumalaya forte 30 pills muscle relaxants kidney failure. For example buy cheap rumalaya forte 30pills online back spasms yoga, a typical goal is that a patient will report a reduction in pain from 8 to 4 on a scale of 0 to 10 in three hours. A goal statement is a nursing order that must be patient centered and specify a desired behavior to occur at a specified time. The behavior must be observable and measurable and the goal statement must specify criteria for measuring the behavior. If the patient’s decision-making ability is impaired, then the patient’s family or another support person becomes the patient’s advocate in the planning process. It is critical that the patient adopts the goal statement; otherwise, the goal might not be achieved. For example, if the patient doesn’t believe in taking pain medica- tion, then a goal of reducing pain by taking analgesics will not be met. The nurse will then have to explore alternatives to pain medication such as a massage or imagery. The care plan should be shared with the patient’s family, the healthcare team and others who are caring for the patient so that everyone is working toward the same goals. A more realistic goal is for the frequency of the patient’s coughing to decrease after each dose. The deadline might be that the patient will take dextromethorphan for 48 hours and report a decrease in frequency of coughing and experience uninterrupted rest. This goal is both observable and measurable since the nurse can observe if the patient is cough- ing and measure the frequency of the cough to determine if the goal is reached. An intervention must complement the goal statement, use available resources, follow protocols established by the healthcare facility, and always keep the patient’s safety in mind. Nurse-initiated intervention A nurse-initiated intervention is a nursing order performed independently by the nurse based on a scientific rationale that benefits the patient in a predicted way, such as removing a blanket to lower the patient’s temperature. Physician or advanced practice intervention This type of intervention is a dependent function issued by a physician or an advanced practitioner that is carried out by a nurse, such as administering pre- scribed medication to the patient. Collaborative intervention A collaborative intervention is an activity performed among multiple healthcare professionals, such as physical therapy for the patient. However, if one or more goals are not realized, reassessment or data collection should occur. This would include reassessing the patient and other factors, such as schedules, availability of resources, and developing new goals, inter- ventions, and evaluations. Teaching the Patient About Drugs A critical nursing responsibility is to educate the patient and the patient’s family about the medication that is administered to the patient or that is self-administered by the patient. Teaching should be conducted in a comfortable environment in a language that both the patient and the patient’s family understand. It is always a good idea to give the patient and family members material that they can take home and review at their leisure. It is very important that written information be at a reading level that can be understood by the patient and family. For example, show the proper injection techniques if the patient requires insulin injections or the correct use of bronchodilator inhalers for asthma. Make sure to have the patient and family members show you how they plan to give the medication. This is especially critical when medication is given using a syringe, topical drugs, and inhalers. The patient and the caregiver must have visual acuity, manual dex- terity, and the mental capacity to prepare and administer medication. Prompt the patient and family members to give you feedback from your les- son and demonstration by asking: • What things help you take your medicine? It is very important that the patient and family members be informed about the signs and symptoms of an allergic response to the medication such as urticaria (hives), swollen lips, hoarse voice, difficulty breathing, and shortness of breath—an indication of life threatening anaphylaxis. In addition to the signs and symptoms of an allergic response, you must also discuss side effects and toxic effects of the medication and any dietary consid- erations the patient must follow while on the medication. Therefore, the nurse needs to de- velop a medication plan to help the patient manage the medication schedule. These influences include the patient’s belief about health such as: • What healthcare can do for the patient • The patient’s susceptibility to disease • The benefits of taking steps to prevent disease • What makes a patient seek healthcare • What makes a patient follow healthcare guidelines For example, a patient who is a coal miner may believe that all coal miners will eventually have lung cancer. Another patient may avoid taking pain medication for fear that they might become addicted. For example, although garlic does lower blood pressure, taking garlic as an herbal cure might be dangerous if the patient is also taking antihypertensive medication because the patient’s blood pressure could be lowered too much. Herbal reme- dies are preferred by some cultures over traditional Western medicine and some patients continue herbal treatment even when a mild illness progresses to a crit- ical level. A patient may refuse any treatment because of the sole belief in the healing power of prayer. Healthcare providers must be nonjudgmental and tolerate alternative beliefs in healthcare even if those beliefs are harmful to the patient. When con- fronted with cultural differences that can result in an adverse effect to the patient, healthcare providers can educate the patient about the benefits of medications and treatment and the risk that the patient is exposed to by not following rec- ommended treatment. This information is sometimes best given while the health- care provider is assessing the patient. The nurse should be careful to remain nonjudgmental about the patient’s decisions. Cultural beliefs can also influence who makes healthcare decisions for the family. However, in some cultures, although the female is responsible for providing and obtaining care, the oldest male is seen as the head of the family and the authority figure for making overall decisions such as when to access healthcare. The way the patient communicates with healthcare providers is greatly influ- enced by individual culture. Here are factors to consider when communicating with a patient: • Eye contact might not be appropriate. Always address the patient formally until the patient gives permission to be addressed informally. Other- wise, the patient may be unable to comply with the appropriate medication schedule. In some cultures, patients don’t want anyone standing or sitting too close and they feel uncomfortable if someone touches them. The elderly are revered in some cultures and the family goes to great lengths to care for them. In other cultures, the family leaves the elderly to die peacefully without interference. As you’ll recall from Chapter 2, pharmaco- genetics is the study of the influence genetics have on a drug response.
During the 1920s best buy rumalaya forte muscle relaxant for anxiety, Piaget was administering intelligence tests to children in an attempt to determine the kinds of logical thinking that children were capable of buy discount rumalaya forte 30 pills online spasms of the bladder. In the process of testing the children purchase generic rumalaya forte from india muscle relaxant drugs specifically relieve muscle, Piaget became intrigued, not so much by the answers that the children got right, but more by the answers they got wrong. Piaget believed that the incorrect answers that the children gave were not mere shots in the dark but rather represented specific ways of thinking unique to the children‘s developmental stage. Just as almost all babies learn to roll over before they learn to sit up by themselves, and learn to crawl before they learn to walk, Piaget believed that children gain their cognitive ability in a developmental order. These insights—that children at different ages think in fundamentally different ways—led to Piaget‘s stage model of cognitive development. Piaget argued that children do not just passively learn but also actively try to make sense of their worlds. He argued that, as they learn and mature, children develop schemas—patterns of knowledge in long-term memory—that help them remember, organize, and respond to information. Furthermore, Piaget thought that when children experience new things, they attempt Attributed to Charles Stangor Saylor. Piaget believed that the children use two distinct methods in doing so, methods that he called assimilation andaccommodation (see Figure 6. If children have learned a schema for horses, then they may call the striped animal they see at the zoo a horse rather than a zebra. In this case, children fit the existing schema to the new information and label the new information with the existing knowledge. When a mother says, ― “No, honey, that‘s a zebra, not a horse,‖ the child may adapt the schema to fit the new stimulus, learning that there are different types of four-legged animals, only one of which is a horse. Piaget‘s most important contribution to understanding cognitive development, and the fundamental aspect of his theory, was the idea that development occurs in unique and distinct stages, with each stage occurring at a specific time, in a sequential manner, and in a way that allows the child to think about the world using new capacities. Object permanence Children acquire the ability to internally represent the Theory of mind; rapid world through language and mental imagery. They also increase in language Preoperational 2 to 7 years start to see the world from other people‘s perspectives. They can Concrete increasingly perform operations on objects that are only operational 7 to 11 years imagined. Conservation Adolescents can think systematically, can reason about Formal 11 years to abstract concepts, and can understand ethics and scientific operational adulthood reasoning. Abstract logic The first developmental stage for Piaget was the sensorimotor stage, the cognitive stage that begins at birth and lasts until around the age of 2. It is defined by the direct physical interactions that babies have with the objects around them. During this stage, babies form their first schemas by using their primary senses—they stare at, listen to, reach for, hold, shake, and taste the things in their environments. Piaget found, for instance, that if he first interested babies in a toy and then covered the toy with a blanket, children who were younger than 6 months of age would act as if the toy had disappeared completely—they never tried to find it under the blanket but would nevertheless smile and reach for it when the blanket was removed. Piaget found that it was not until about 8 months that the children realized that the object was merely covered and not gone. Piaget used the term object permanence to refer to the child’s ability to know that an object exists even when the object cannot be perceived. Video Clip: Object Permanence Children younger than about 8 months of age do not understand object permanence. At about 2 years of age, and until about 7 years of age, children move into thepreoperational stage. During this stage, children begin to use language and to think more abstractly about objects, but their understanding is more intuitive and without much ability to deduce or reason. The thinking is preoperational, meaning that the child lacks the ability to operate on or transform objects mentally. In one study that showed the extent of this inability,  Judy DeLoache (1987) showed children a room within a small dollhouse. The researchers took the children to another lab room, which was an exact replica of the dollhouse room, but full-sized. Three-year-old children, on the other hand, immediately looked for the toy behind the couch, demonstrating that they were improving their operational skills. The inability of young children to view transitions also leads them to be egocentric—unable to readily see and understand other people‘s viewpoints. Developmental psychologists define the theory of mind as the ability to take another person’s viewpoint, and the ability to do so Attributed to Charles Stangor Saylor. In one demonstration of the development of theory of mind, a researcher shows a child a video of another child (let‘s call her Anna) putting a ball in a red box. Then Anna leaves the room, and the video shows that while she is gone, a researcher moves the ball from the red box into a blue box. The child is then asked to point to the box where Anna will probably look to find her ball. Children who are younger than 4 years of age typically are unable to understand that Anna does not know that the ball has been moved, and they predict that she will look for it in the blue box. After 4 years of age, however, children have developed a theory of mind—they realize that different people can have different viewpoints, and that (although she will be wrong) Anna will nevertheless think that the ball is still in the red box. After about 7 years of age, the child moves into the concrete operational stage, which is marked by more frequent and more accurate use of transitions, operations, and abstract concepts, including those of time, space, and numbers. An important milestone during the concrete operational stage is the development of conservation—the understanding that changes in the form of an object do not necessarily mean changes in the quantity of the object. Children younger than 7 years generally think that a glass of milk that is tall holds more milk than a glass of milk that is shorter and wider, and they continue to believe this even when they see the same milk poured back and forth between the glasses. It appears that these children focus only on one dimension (in this case, the height of the glass) and ignore the other dimension (width). However, when children reach the concrete operational stage, their abilities to understand such transformations make them aware that, although the milk looks different in the different glasses, the amount must be the same. Video Clip: Conservation Children younger than about 7 years of age do not understand the principles of conservation. At about 11 years of age, children enter the formal operational stage, which is marked by the ability to think in abstract terms and to use scientific and philosophical lines of thought. For instance, rather than haphazardly changing different aspects of a situation that allows no clear conclusions to be drawn, they systematically make changes in one thing at a time and observe what difference that particular change makes. They learn to use deductive reasoning, such as ―“if this, then that,‖ and they become capable of imagining situations that “might be,‖ rather than just those that actually exist. Piaget‘s theories have made a substantial and lasting contribution to developmental psychology. His contributions include the idea that children are not merely passive receptacles of information but rather actively engage in acquiring new knowledge and making sense of the world around them. This general idea has generated many other theories of cognitive development, each designed to help us better understand the development of the child‘s information-processing  skills (Klahr & McWinney, 1998; Shrager & Siegler, 1998).
In the United States rumalaya forte 30pills line muscle relaxant and pain reliever, medical examiners and coroners do not require special permission to measure ethanol (or any drug for that matter) rumalaya forte 30 pills lowest price spasms while sleeping, and they do so routinely buy cheap rumalaya forte skeletal muscle relaxants quiz. However, no fixed relation- ship between postmortem blood and vitreous concentrations is recognized in law. Additionally, when bodily harm has resulted, or when there is evidence of criminal activity (such as leaving the scene of an accident), then it is within the power of the officer to order that blood be drawn, even if the suspect is unwilling or unconscious. Police Station Procedure Police may require a suspect to provide either two breath samples for analysis by means of an approved device or a sample of blood or urine for laboratory testing. This is usually done at a police station, because it is almost unheard of for a hospital in the United Kingdom or the United States to be equipped with an evidentiary breath testing device. This situation does not occur in the United States where, if appropriate staff are available, both blood and urine may be obtained at the police station. In the United Kingdom, if a specimen other than breath is required, police may demand either a urine or blood test. If blood cannot be obtained as, for example, might well be the case in a chronic intravenous drug abuser, then a Traffic Medicine 365 urine sample must be provided within 1 hour of the request for its provision being made and after the provision of a previous specimen of urine. In the United States, urine specimens are generally not considered admissible proof of intoxication. A large number of studies have shown that the ratio between blood alcohol and pooled urine is highly unreliable and unpredictable (35,36). Collection of ureteral urine is often attempted at autopsy, but for obvious reasons, is not an option with living patients. Only officers who are trained to use the machine are allowed to conduct the intoximeter procedure, and the lower of two readings is taken. The subject must not have smoked for 10 min- utes or have consumed alcohol or used a mouth spray or mouthwash, taken any medication, or consumed any food for 20 minutes before the breath test. If the reading is below the prescribed limit of 35 μg of alcohol per 100 mL of breath, no action is taken unless impairment through drugs is suspected. If the level is between 36 and 39, no prosecution can occur unless there is impairment. If the level is between 40 and 50, the person is given the option of having the breath sample reading replaced by a specimen of blood or urine, but it is for the police officer to decide which, in accordance with Section 7. Different rules and regulations, but with much the same intent, apply in other countries. Blood Samples It is wise to have a standardized routine for this procedure, if only to help prevent some of the technical defenses that are frequently raised in court. Regardless of whether or not a kit is used, appropriate chain of custody forms must be completed, and the record must reflect that alcohol-containing swabs were not used to cleanse the skin (actually, studies have shown that alcohol swabs contribute negligibly to the final result, but the issue is routinely raised in court) (37). The police officer should identify the doctor to the person, and the doctor should obtain witnessed informed consent. The physician must then determine whether there are any medical reasons why a sample of blood cannot be taken. The sample should be divided equally between the two bottles and shaken to dis- 366 Wall and Karch perse the preservative (an additional needle through the rubber membrane helps to equalize the pressure). The bottles should be labeled and placed in the secure containers and caps applied. The driver is allowed to retain one sample, which is placed in an envelope and sealed. Under British law, a forensic physician may make up to three unsuccessful attempts at taking blood before the driver can reasonably refuse to give blood on grounds that the defendant has lost confidence in the doctor. Complex Defenses Numerous technical defenses have been advocated over the years, and doctors should be aware of the most common. In the United States, refusal leads to automatic license suspension and, in some states, may actually constitute a separate crime; police are under an obligation to ensure that drivers are made aware of that. The motorist must understand the manda- tory warning of prosecution if a specimen is not produced. Failure to under- stand, at least in the United Kingdom, is a reasonable excuse for the nonprovision of a sample (38). The decision regarding whether there is a medi- cal reason not to supply a sample of breath is left to the police officer and is summarized in case law. There is no provision or requirement at that stage for a doctor to be summoned or to give an opinion. Examples of medically acceptable reasons include mouth, lip, or facial injury; tracheotomy; rib injury; and neurological problems. Traffic Medicine 367 Many cases have been challenged on the basis that the person was unable to blow into the intoximeter because of respiratory problems. This article was particularly useful because most forensic physicians do not have access to spirometry but do have access to a simple peak flow reading in the custody situation. A more recent study (45) on the new Lion Intoxilyzer 6000 concluded that some subjects with lung diseases may have difficulty in providing evi- dential breath samples. However, these were subjects who would generally have been considered to have severe lung diseases. A recent fashionable defense is that the presence of a metal stud through a hole pierced in the tongue invalidates the breath alcohol test because of the prohibition against foreign substances in the mouth and because of the poten- tial for the jewelery to retain alcohol and interfere with the breath test. How- ever, experimental work has shown that the rates of elimination of mouth alcohol were no different in subjects with a tongue stud as opposed to controls and that for the purposes of breath alcohol testing, oral jewelery should be treated the same as metallic dental work and left in place without affecting the outcome of the breath test (46). Failure to Provide a Sample of Blood First, there must be a definite request to provide a sample of blood. Where the sample of blood is taken from is solely the choice of the forensic physician (or, in the United States, the emergency room physician). In Solesbury v Pugh (48), the defendant was found guilty of failing to supply a specimen as he would only allow a sample to be taken from his big toe, which the doctor was not prepared to do. In the United Kingdom, if the patient’s own doctor and forensic physi- cian are both present, the person can choose which doctor takes the sample. Similar rules apply in the United States, where statutes generally spell out that financial responsibility for such services rests with the driver and not the state. In the United Kingdom, if a blood sample is provided but the doc- tor spills the sample, then the law has been complied with on the basis that removal of the syringe from the vein by the doctor completes the provision of the specimen by the defendant (50). In the United Kingdom, a minimum of 2 mL of blood is required (the laboratory requires a minimum of 1 mL for analysis) for an adequate sample (51). If less than this is obtained, the sample should be discarded and another one attempted or the police officer advised that there is a medical reason why a sample of blood should not be provided and the urine option can then be selected. In the early 1980s, one police force purchased and used swabs containing alcohol with the result that numerous convictions were later overturned (52). Probably the most common defense for failure to provide a sample of blood is that of needle phobia. If this is alleged, a full medical history should be obtained and enquiry made of whether the person has had blood tests before, whether ears or other parts of the body have been pierced, or whether there have been foreign travel immunizations or any other medical or dental procedure undertaken in which an injection may have been administered.
M. Hamlar. Trinity College of Florida.