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By D. Tangach. University of Kansas Medical Center.

On two or three occasions he has hurt his knees on falling cheap 12.5mg lopressor amex, and on one other occasion he hit his head cheap lopressor 25 mg on line. He has an occasional cough with some white sputum but he cannot remember whether he was coughing at the time of any of the falls generic 100 mg lopressor fast delivery. He was diagnosed as having hypertension at a routine well man clinic 4 years ago, and has been on treatment with a diuretic, bendrofluazide and doxazosin, for this. The blood pressure has been checked in the surgery on three or four occasions and he was told that it has been well controlled. He was found to have a high fasting blood sugar 6 months before and had been advised a diabetic diet. The heart sounds are normal and there is nothing abnormal to find on examination of the respi- ratory system or gastrointestinal system. In the nervous system, there is a little loss of sensation to light touch in the toes, but no other abnormalities. Some more information in the history about the circumstances of these falls would be helpful. On further enquiry, it emerges that the falls are most likely to occur when he gets up from bed first thing in the morning. The afternoon events have occurred on getting up from a chair after his post-lunch doze. This was verified by measurements of standing and lying blood pressure – the diagnostic criteria are a drop of 15 mmHg on standing for 3 min. This showed a marked postural drop with blood pressure decreasing from 134/84 to 104/68 mmHg. This is most likely to be caused by the antihypertensive treatment; both the alpha-blocker which causes vasodilatation and the diuretic might contribute. Another possible candidate for a cause of the postural hypoten- sion is the diabetes which could be associated with autonomic neuropathy. In this case the diabetes is not known to have been present for long and there is evidence of only very mild peripheral sensory neuropathy. Diabetic autonomic neuropathy is usually associated with quite severe peripheral sensory neuropathy, with or without motor neuropathy. Clinically, it is easily mistaken for atrial fibrillation because of the irregular rhythm and the variation in strength of beats. It may be associated with episodes of bradycardia and/or tachycardia which could cause falls. The positive intrathoracic pressure during coughing limits venous return to the heart. The cough is usually quite marked and he might be expected to remember this since he gives a good account of the falls otherwise. Neck movements with vertebrobasilar disease, poor eyesight and problems with balance are other common causes of falls in the elderly. A neurological cause, such as transient ischaemic episodes and epilepsy, is less likely with the lack of prior symptoms and the swift recovery with clear consciousness and no neuro- logical signs. Another diagnosis which should be remembered in older people who fall is a subdural haematoma. The doxazosin should be stopped and another antihypertensive agent started if necessary. The blood pressure rose to 144/86 mmHg lying and 142/84 mmHg standing, indicating no significant postural hypotension, with reasonable blood-pressure control. On direct questioning she says that she has felt increasingly tired for around 2 years. She was diagnosed with hypothyroidism 8 years ago and has been on thyroxine replacement but has not had her blood tests checked for a few years. Her other complaints are of itching for 2–3 months, but she has not noticed any rash. She says that her mouth has been dry and, on direct questioning, thinks her eyes have also felt dry. There has been no disturbance of her bowels or urine although she thinks that her urine has been rather ‘strong’ lately. She has taken occasional paracetamol for headaches but has been on no regular medication other than thyroxine and some vitamin tablets she buys from the chemist. Examination Her sclerae look a little yellow and she has xanthelasmata around the eyes. In the abdomen, the liver is not palpable but the spleen is felt 2 cm under the left costal margin. The symptoms and investigations are characteristic of primary biliary cirrhosis, an uncommon condition found mainly in middle-aged women.

The etiology may be represented by past experiences of the individ- ual buy lopressor 12.5mg overnight delivery, genetic influences generic 25 mg lopressor with mastercard, current environmental factors discount 100mg lopressor with mastercard, or patho- physiological changes. The defining characteristics describe what the client says and what the nurse observes that indicate the existence of a particular problem. This book may be used as a guide in the construction of care plans for various psychiatric clients. The use of this format is not to imply that nursing diagnoses are based on, or flow from, medical diagnoses; it is meant only to enhance the usability of the book. In addition, I am not suggest- ing that those nursing diagnoses presented with each psychiatric category are all-inclusive. It is valid, however, to state that certain nursing diagnoses are indeed common to individuals with specific psychiatric dis- orders. The diagnoses presented in this book are intended to be used as guidelines for construction of care plans that must be individualized for each client, based on the nursing assessment. The interventions can also be used in areas in which interdisci- plinary treatment plans take the place of the nursing care plan. The Disorder: A definition and common types or categories that have been identified. Predisposing Factors: Information regarding theories of etiology, which the nurse may use in formulating the “re- lated to” portion of the nursing diagnosis, as it applies to the client. Symptomatology: Subjective and objective data identifying behaviors common to the disorder. These behaviors, as they apply to the individual client, may be pertinent to the “evi- denced by” portion of the nursing diagnosis. Possible Etiologies (“related to”): This section suggests possible causes for the problem identified. Note: Defining characteristics are replaced by “related/risk factors” for the “Risk for” diagnoses. Defining Characteristics (“evidenced by”): This section in- cludes signs and symptoms that may be evident to indicate that the problem exists. Goals/Objectives: These statements are made in client behav- ioral objective terminology. They are measurable, short- and long-term goals, to be used in evaluating the effectiveness of the nursing interventions in alleviating the identified problem. There may be more than one short-term goal, and they may be considered “stepping stones” to fulfillment of the long-term goal. For purposes of this book, “long-term,” in most instances, is designated as “by discharge from treatment,” whether the client is in an inpatient or outpatient setting. Interventions with Selected Rationales: Only those inter- ventions that are appropriate to a particular nursing diagno- sis within the context of the psychiatric setting are presented. Rationales for selected interventions are included to provide clarification beyond fundamental nursing knowledge, and to assist in the selection of appropriate interventions for indi- vidual clients. Important interventions related to communi- cation may be identified with the icon. Outcome Criteria: These are behavioral changes that can be used as criteria to determine the extent to which the nurs- ing diagnosis has been resolved. To use this book in the preparation of psychiatric nursing care plans, find the section in the text applicable to the client’s psychiatric diagnosis. Select nursing interventions and outcome criteria appropriate to the client for each nursing diagnosis identified. Include all of this information on the care plan, along with a date for evaluating the status of each problem. On the evaluation date, document success of the nursing inter- ventions in achieving the goals of care, using the desired client outcomes as criteria. Topics related to forensic nursing, psychiatric home nurs- ing care, and complementary therapies are also included. This information should facilitate use of the book for nurses adminis- tering psychotropic medications and also for nurse practitioners with prescriptive authority. Information is pre- sented related to indications, actions, contraindications and pre- cautions, interactions, route and dosage, and adverse reactions and side effects. Examples of medications in each chemical class are presented by generic and trade name, along with information about half-life, controlled and pregnancy categories, and avail- able forms of the medication. Nursing diagnoses related to each category, along with nursing interventions, and client and family education are included in each chapter. Another helpful feature of this text is the table in Appendix N, which lists some client behaviors commonly observed in the psychiatric setting and the most appropriate nursing diagnosis for each. It is hoped that this information will broaden the un- derstanding of the need to use a variety of nursing diagnoses in preparing the client treatment plan. The book is de- signed to be used as a quick reference in the preparation of care plans, with the expectation that additional information will be required for each nursing diagnosis as the nurse individualizes care for psychiatric clients. The nursing process has been identified as nursing’s scien- tific methodology for the delivery of nursing care. The curricula of most nursing schools include nursing process as a component of their conceptual frameworks.

What about each of these individu- Which of these skills do you personally pos- als causes you to respect his/her human dig- sess and which do you need to develop in nity? Describe what the following words mean to you and how they apply to your use of the nursing process: a cheap 25mg lopressor visa. Follow three different nurses on their daily rounds of patients 100 mg lopressor sale, noticing how they relate b 50 mg lopressor with amex. Does their attitude say “drop dead,” “you mean nothing to me,” or “I care about you”? Briefly explain how the following considera- tions are relevant to the successful use of crit- ical thinking competencies: 9. Nurses skilled in developing caring relationships often need to direct the conver- a. Develop four opening statements/questions designed to elicit information from a patient that you b. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Horvath is scheduled to learn how to perform wound care for her daughter at home but has missed every planned teaching session thus far. Assess your personal blend of the skills nurses vath works the evening shift and has a babysit- need: cognitive, technical, interpersonal, and ter stay with her children from immediately ethical/legal. What skills do you need to develop to meet the needs of those entrusted to your care? How might the nurse use blended nursing skills to respond to this patient situation? How might the school of nursing use the nursing process to address one or more of these problems? Do you as a nursing student have an obligation to address the health prob- lems you encounter? What intellectual, technical, interpersonal, How did you reach your final decision? Relate and/or ethical/legal competencies are most the method you used in your life to the mod- likely to bring about the desired outcome? How might this knowledge help you to understand your responses to patients with different personal- ity traits? Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Which of the following sources of patient data is usually the primary and best source? Smith is admitted to the hospital with patient are known as: complaints of left-sided weakness and difficulty a. Brain scan shows evidence of a clot in the nurse–patient interview does the nurse gather middle cerebral artery. Which of the following nurse–patient ted to the hospital with complaints of positioning facilitates an easy exchange of difficulty urinating, bloody urine, and burning information? Focusing on altered patterns of elimination their chairs are at right angles to each common in the elderly other, 1 foot apart. If the patient is in bed, the nurse sits in a patient’s sexual history chair placed at a 45-degree angle to the bed. If the patient is in bed, the nurse stands at validate data on the patient’s record the side of the bed. Nursing assessments duplicate medical becomes very tired, but there are still questions assessments. Jones if she objects to your database for problem solving and care interviewing her husband to obtain the planning. Anderson, age 50, is admitted to your focus of Gordon’s functional health patterns unit with the diagnosis of scleroderma. Elimination, activity, sleep, and sexuality occur during the preparatory phase of the are components of the assessment and data nursing interview? The nurse assesses the patient’s comfort hands before signing a consent for surgery. A patient feels nauseated after eating his reading current and past records and reports. A patient complains of being cold and describe the unique focus of nursing requests an extra blanket. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. When the nurse compares the current status of a patient to the initial assessment performed 1. Place the following actions performed by a during the admitting process, he/she is nurse during a patient interview in the order in performing a(n) type of which they would most likely occur. The nurse gathers all the information must be collected from every patient in a needed to form the subjective database. The nurse prepares to meet the patient by reading current and past records and reports.

I wish also to thank the following friends and colleagues for proof-reading chapters and supplying information: Dr buy lopressor 12.5 mg free shipping. Finally buy lopressor 50 mg with amex, I would like to thank my wife for her support whilst I was writing the text discount 25mg lopressor with amex. Some of these naturally occuring compounds and ions (endogenous species) are present only in very small amounts in specific regions of the body, whilst others, such as peptides, proteins, carbohydrates, lipids and nucleic acids, are found in all parts of the body. A basic knowledge of the nomenclature and structures of these more common endogenous classes of biological molecules is essential to under- standing medicinal chemistry. This chapter introduces these topics in an attempt to provide for those readers who do not have this background knowledge. The structures of biologically active molecules usually contain more than one type of functional group. This means that the properties of these molecules are a mixture of those of each of the functional groups present plus properties characteristic of the compound. The latter are frequently due to the interaction of adjacent functional groups and/or the influence of a functional group on the carbon–hydrogen skeleton of the compound. This often involves the electronic activation of C–H bonds by adjacent functional groups. Their structures contain both an amino group, usually a primary amine, and a carboxylic acid. The structures of amino acids can also contain other functional groups besides the amine and carboxylic acid groups (Table 1. Methionine, for example, contains a sulphide group, whilst serine has a primary alcohol group. Amino acids with hydrophobic side chains will be less soluble in water than those with hydrophilic side chains. The hydrophobic/hydrophilic nature of the side chains of amino acids has a considerable influence on the conformation adopted by a peptide or protein in aqueous solution. Furthermore, the hydrophobic/hydro- philic balance of the groups in a molecule will have a considerable effect on the ease of its passage through membranes (Appendix 5). In aqueous solution the structure of amino acids are dependent on the pH of the solution (Figure 1. The pH at which an aqueous solution of an amino acid is electrically neutral is known as the isoelectric point (pI) of the amino acid (Table 1. They are used in the design of electrophoretic and chromatographic analytical methods for amino acids. In peptide and protein structures their structures are indicated by either three letter groups or single letters (Table 1. Amino acids such as ornithine and citrulline, which are not found in naturally occuring peptides and proteins, do not have an allocated three or single letter code (Figure 1. Most naturally occuring amino acids have an L configur- ation but there are some important exceptions. Note that the carboxylic acid group must be drawn at the top and the R group at the bottom of the Fischer projection. They consist of amino acid residues linked together by amide functional groups (Figure 1. The lone pair of its nitrogen atom is able to interact with the p electrons of the carbonyl group. Regulatory These are proteins that control the physiological activity of other proteins. Transport These transport specific compounds from one part of the body to another haemoglobin transports carbon dioxide too and oxygen from the lungs. Cell membranes contain proteins that are responsible for the transport of species from one side of the membrane to the other. Some form part of the bodies immune system defending the body against foreign molecules and bacteria. Others, such as the blood clotting agents thrombin and fibrinogen, prevent loss of blood when a blood vessel is damaged. Adapted from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, published by Prentice Hall, a Pearson Education Company This electron delocalization is explained by p orbital overlap and is usually shown by the use of resonance structures (Figure 1. For example, haemo- globin is a conjugated protein because its structure contains a haem residue (Figure 1. These non-amino-acid residues are known as prosthetic groups when they are involved in the biological activity of the molecule. Conjugated proteins are classified according to the chemical nature of their non-amino-acid component. For example, glycoproteins contain a carbohydrate residue, haemoproteins a haem group and lipoproteins a lipid residue. These chains may be branched due to the presence of multi-basic or acidic amino acid residues in the chain (Figure 1. In addition, bridges (cross links) may be formed between different sections of the same chain or different chains.

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