By E. Joey. Northland College.

Family health as derived from King’s tainment: Resolving filial caregiver role strain buy genuine tegopen line. Strengthening patient- Council for Nursing Research’s 1998 Pre-Convention provider relationships 250 gm tegopen with visa. Lippincott’s Case Management purchase tegopen 250 gm amex, 7(3), Research Utilization Conference, Evidence-based Practice, 86–102. Application of King’s theory of goal attain- ory—Application in emergency and rural nursing. The these premature epitaphs and notes that her best latter is a critical analysis of the 25 years of model- work is yet to come. Roy often em- based literature, which includes 163 studies phasizes her primary commitment to define and published in 46 English-speaking journals, disser- develop nursing knowledge and regards her work tations, and theses. This project was completed by with the Roy Adaptation Model as one rich source the Boston-Based Adaptation Research Society in of knowledge for clinical nursing. Roy in the interest of advancing nursing based concept of adaptation based on insights practice by developing basic and clinical nursing related to the place of the person in the universe. Roy’s major recent activities was cosmic philosophical and scientific assumptions, cochairing the annual Knowledge Conferences will become the basis for developing knowledge hosted by the Boston College School of Nursing be- that will make nursing a major social force in the tween 1996 and 2001, which developed into a book century to come. Being a teacher and a mentor to and professional growth as her family, her religious doctoral students in nursing is another role that she commitment, and her teachers and mentors. Roy has been a nurse and instilled the values of always seeking to major speaker on topics related to nursing theory, know more about people and their care, and of self- research, curriculum, clinical practice, and profes- less giving as a nurse. Roy has played a major role in at least 35 as a maid, and finally as a nurse’s aid. Her college education began on nursing knowledge have appeared in Image: with a bachelor of arts degree with a major in nurs- Journal of Nursing Scholarship, Nursing Science ing at Mount St. Mary’s College, Los Angeles, fol- Quarterly, Scholarly Inquiry for Nursing Practice, lowed by master’s degrees in pediatric nursing and Biological Research for Nursing, and other journals. Roy’s current clinical nurse scholar in a two-year postdoctoral program in research continues her long-time interest in neuro- neuroscience nursing at the University of California science. Important mentors in her life have cognitive recovery and is working with families to included Dorothy E. Johnson, Ruth Wu, Connie use information processing practice to help pa- Robinson, and Barbara Smith Moran. Roy is still best known for developing and well as promoting adaptation of patients with acute continually updating the Roy Adaptation Model as and chronic health challenges. Books on the model have been translated into many languages, including Introducing the Theory French, Italian, Spanish, Finnish, Chinese, Korean, and Japanese. Roy The Roy Adaptation Model has been in use for considers of great significance are The Roy approximately 35 years, providing direction for Adaptation Model (2nd edition), written with nursing practice, education, administration, and Heather Andrews (Appleton & Lange); and The Roy research. The coping tributed to model-based knowledge for nursing processes are broadly described within the regula- practice. The purpose of this chapter is to describe tor and cognator subsystems for the individual and the use of the model in developing knowledge for within the stabilizer and innovator subsystems for practice, with particular emphasis on research with groups. A study of coping, adaptation, and self- listic adaptive systems interact with the internal consistency in the elderly with hearing impairment and external environment, transform the environ- provides an example of some of the key concepts ment, and are transformed by it. A particular aspect of the model, as well as a research design to test of the internal environment is the adaptation level. Specifically, This is the name given to the three possible condi- the study provides a test of a generic proposition tions of the life processes of the human adaptive derived from the Roy Adaptation Model. But first, system: integrated, compensatory, and compro- a brief review of the Roy Adaptation Model is mised (Roy & Andrews, 1999). Processing of the in- provided, with emphasis on recent developments of ternal and external environment by the coping the theoretical work and its use in nursing research. Four Then, the theoretical and empirical concepts of cop- categories for assessing behaviors are termed ing and adaptation processing and self-consistency “adaptive modes. Central to Roy’s theoretical model is the belief that adaptive responses support health, The Roy Adaptation Model (Roy, 1984, 1988a, 1988b; Roy & Andrews, 1991, 1999; Roy & Roberts, 1981) provides the framework for programs of Adaptive responses support health, which nursing research, particularly the constructs for the is defined as a state and a process of being research exemplar involving elderly patients with and becoming integrated and whole. Scientific assumptions for the Roy has described strategies for knowledge devel- model have been based on general systems theory opment based on the model and a structure of and adaptation-level theory (Roy & Corliss, 1993). Knowledge-development strategies that she to include Roy’s redefinition of adaptation for the has integrated through decades of work include twenty-first century (Roy & Andrews, 1999). The model construction; theory development (includ- cosmic unity stressed in Roy’s vision for the future ing concept analysis, synthesis, and derivation of emphasizes the principle that people and the earth propositional statements); philosophic explication; have common patterns and integral relationships. The structure for knowledge emphasis shifts to the purposefulness of human includes the broad categories of the basic and existence in a universe that is creative. The clini- People, both individually and in groups, are viewed cal science of nursing investigates specifically the as holistic adaptive systems, with coping processes role of the nurse in promoting adaptation and acting to maintain adaptation and to promote per- human and environment transformations. Cognitive recovery from head injury was the adaptive patterns; (2) the adaptive modes; that is, focus of the research. The first study used a re- their development, interrelatedness, and cultural peated measures design to describe changes in cog- and other influences; and (3) adaptation related to nitive performance over six months of recovery for health, particularly person and environment inter- 50 patients (Roy, 1985). The initial pilot study of nine matched stabilizer-innovator effectiveness; (2) changes pairs shows some promising trends.

Hypoglycemia can result from not eating at regular intervals order generic tegopen from india, in- tense physical activity purchase generic tegopen pills, taking too much medication buy generic tegopen canada, or drinking alcohol. Blood glucose levels can drop quickly, and in severe cases can lead to loss of consciousness and sei- zures, so it is important to act quickly and eat or drink a fast-acting carbohydrate such as glucose tablets, honey, juice, or candy to raise blood sugar levels. It is found in brewer’s yeast, whole grains (especially wheat germ), onions, and garlic. Note: To promote steady blood sugar levels, eat small, frequent meals (every three hours). Foods to avoid: • Alcohol can cause either high or low blood sugar depending on how much you drink and if you are eating while drinking. Studies have also found that those who eat high-glycemic diets are also at increased risk of developing type 2 diabetes. Aim for 30 minutes to one hour of moderate intensity activity each day, such as brisk walking, cycling, or swimming. Exercise helps with weight manage- ment and also improves blood glucose control and insulin sensitivity. People with diabetes who smoke are at greater risk for heart, kidney and eye disease, and nerve damage. Brush your teeth at least twice a day and floss daily to reduce the risk of gum infection. Diabetics are prone to nerve damage, which can make sores on the feet unnoticeable and delay wound healing. Top Recommended Supplements Alpha lipoic acid: A powerful antioxidant that can help improve insulin sensitivity and reduce the risk of diabetic complications such as neuropathy and nephropathy (kidney dis- ease). Some studies have found that diabetics are deficient in chromium, and that supplements can help improve blood sugar management. Studies involving fibre supplements of psyllium, oat bran, and glucomannan have shown benefits for diabet- ics. Complementary Supplements B-vitamins: Essential for proper nerve function and energy metabolism. Take a B-complex or a multivitamin that contains at least 50 mg of the B-vitamins. Fenugreek: Seeds and supplements containing this herb have been shown to lower blood sugar and improve insulin sensitivity. Fish oil: Helps improve glucose tolerance, reduce triglycerides and cholesterol levels, and may help improve diabetic complications (neuropathy and nephropathy). Gymnema: Preliminary research shows that this herb can help stimulate insulin secretion and improve blood glucose control in those with both Type 1 and Type 2 diabetes. Dosage: 400 mg once or twice daily of a product standardized to 25 percent gymnemic acid. People with diabetes tend to have low magnesium levels and a deficiency is associated with insulin resistance. Vitamin E: Helps to improve glucose tolerance and reduce glycosylation (binding of sugar to proteins in blood vessels). Many studies have found that it can prevent and reverse nerve damage and help protect against retinopathy and nephropathy. Eat small, frequent meals with low-glycemic, high-fibre carbohydrates, protein, and healthy fats. Maintain good oral and foot hygiene and see your doctor regularly for checkups and blood glucose testing. Diarrhea is considered acute if it lasts just a few days or chronic if it persists for more than four weeks. During digestion, the food we eat is broken down and nutrients are absorbed through the intestine. The waste material passes through the colon where most of the fluids are absorbed, creating a soft stool. The body secretes extra fluid and intestinal contrac- tions propel the toxins out of the body. When diarrhea occurs, the food and fluids D you eat pass quickly through the colon so that the fluids are not adequately absorbed, causing soft, watery stools. Chronic diarrhea can occur due to digestive disorders or use of medications that affect bowel function. Aside from being unpleasant and embarrassing, diarrhea can lead to serious com- plications such as dehydration and nutrient deficiencies. In some cases it will clear up on its own, and in other cases treatment is necessary to get it under control and prevent complications. However, to prevent dehydration, your doctor will advise you to increase fluid intake.

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Margaret Newman (1994a) defines con- Newman (1994b) goes on to state that few expe- sciousness as rience the sixth stage purchase tegopen no prescription, unbinding buy tegopen cheap, or the seventh the information of the system: The capacity of the stage discount 250gm tegopen amex, real freedom, unless they have had these system to interact with the environment. In the experiences of transcendence characterized by the human system the informational capacity includes fifth stage. It is in the moving through the choice not only all the things we normally associate with point and the stages of decentering and unbinding consciousness, such as thinking and feeling, but also that a person moves on to higher levels of con- all the information embedded in the nervous system, sciousness (Newman, 1999). The information of these and other systems reveals the corollary between her theory of Health as complexity of the human system and how the infor- Expanding Consciousness and Young’s theory of mation of the system interacts with the information the Evolution of Consciousness in that we “come of the environmental system. Newman sees fers the image of a smooth lake into which two death as a transformation point, with a person’s stones are thrown. As the stones hit the water, con- consciousness continuing to develop beyond the centric waves circle out until the two patterns reach physical life, becoming a part of a universal con- one another and interpenetrate. Nurses are changed been an expansion of consciousness when there is a by their interactions with their patients, just as pa- richer, more meaningful quality to their relation- tients are changed by their interactions with nurses. Relationships that are more open, loving, This mutual transformation extends to the sur- caring, connected, and peaceful are a manifestation rounding environment and relationships of the of expanding consciousness. The nurse and client may also see movement Newman states: “We have come to see nursing as a through Young’s spectrum of evolving conscious- process of relationship that co-evolves as a func- ness, where people transcend their own egos, dedi- tion of the interpenetration of the evolving fields of cate their energy to something greater than the the nurse, client, and the environment in a self- individual self, and learn to build order against organizing, unpredictable way. It is important the pattern from the outside, but by entering into the that the nurse be able to practice from the center of evolving pattern as it unfolds. It involves being with rather demands that nurses develop tolerance for uncer- than doing for. It is caring in its state of disequilibrium that the potential for deepest, most respectful sense. She states, “The rhythmic relating of process of attending to that which is meaningful. The Somali nurse will have to ask Margaret Newman’s Theory of Health as Expand- more clarifying questions and seek to understand ing Consciousness is being used throughout the that which has not been her experience. No matter world, but it has been more quickly embraced and what the background of the nurse and patient, the understood by nurses from indigenous and Eastern clarifying process, if done in an open, caring, and cultures, who are less bound by linear, three- nonjudging manner, provides great insight for both dimensional thought and physical concepts of participants in the pattern-recognition process as health and who are more immersed in the meta- the nurse and the patient realize their interconnect- physical, mystical aspect of human existence. When the nurse-patient interaction is fo- Increasingly, however, the theory is being enthusi- cused on attending to meaning, it transcends astically embraced by nurses in industrialized na- barriers of culture, gender, age, class, race, educa- tions who are finding it increasingly difficult to tion, and ethnicity. The pilot study informed the methodology unless one has fully comprehended sorrow, and used by Newman and Moch (1991) in their re- vice versa. Although they seem to be opposites, search with people with cardiovascular disease. If you want to see a dark view 20 women diagnosed with breast cancer, cen- pattern more clearly, you would put it against a tering the nurse-patient dialogue on the pattern of light background. Moch asked the women in her study to methodology permits a nurse to be present to a describe what was meaningful to them and found client whose life circumstances are very different that in talking about meaningful people and events, from those of the nurse. For example, the pattern- the sequential patterns of interaction between peo- recognition interaction for a homeless 16-year-old ple and their environment become apparent. After completion of the The interview: After the study has been explained interviews, the data are analyzed more intensely and informed consent obtained, the data collec- in light of the theory of health as expanding tion process begins with the nurse asking the consciousness. Young’s spectrum of conscious- participant a simple, open-ended question such ness is applied, and the quality and complexity as, “Tell me about the most meaningful people of the sequential patterns of interaction are eval- and events in your life. If the intent of the research is to look at a simply about meaningful events, the meaning- group of people or at a community, similarities ful relationships usually arise as the stories are of pattern among participants are identified. Follow-up: At the second interview, the diagram (or Newman states: “Not only is our science a human other visual portrayal) is shared with the partic- science, but, within the context of a practice disci- ipant without any causal interpretation. This kind of theory is participant is given the opportunity to comment embodied in the investigator-nurse. This dialectic situation being addressed by making a difference in process is repeated in subsequent interviews, the situation, as well as being informed by the data with data added to the narrative and the dia- of the situation” (Newman, 1994b, p. In ad- medical disease diagnosis or with similar life cir- dressing long-term implications of this study, cumstances (Newman, 1994). She characterized the perspectives about health as expanding conscious- overall pattern to be one of isolation and being ness. In discussing the implications her research closed in because participants isolated themselves holds for nursing practice, Moch stressed that in- from situations they were unable to deal with and corporating a “health-within-illness experience” avoided any stimuli that could threaten their pul- view has the potential to drastically change the way monary status. They found three common themes: the activity restrictions, and in their inability to pur- need to excel, the need to please others, and feelings of sue what they need and want” (p. These findings were consistent with the Rosenthal (1996) conducted a similar study in the literature on coronary artery disease and personal- United States and found a relationship between ity type. When applying Young’s (1976) theory to pattern recognition and evolving consciousness to the participants, they found that most participants be related to a sense of connectedness, with the par- were caught in a repetitive cycle characteristic of ticipants who manifested a sense of connectedness the centering stage.

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The cricoid cartilage (just below the ‘Adam’s apple’) forms a complete ring cheap tegopen 250gm with mastercard, so cricoid pressure (pressing the cricoid cartilage down with three fingers towards the patient’s head) compresses the pharynx against cervical vertebra order cheap tegopen online, preventing gastric reflux and aspiration buy tegopen 250 gm otc. Accidental single bronchus intubation usually occurs in the right main bronchus, due to its gentler angle from the carina. Endotracheal tubes are manufactured in a single (long) length and so almost invariably require cutting to minimise ventilatory dead space, usually to 21 cm (female) and 23 cm (male). Childrens’ airways differ from those of adults (see Chapter 13) and so, in order to prevent excessive pressure on tracheal tissue, uncuffed endotracheal tubes should be used with children under 8 years old (James 1991); nasal intubation with Tunstall connector fixation can prevent damage from tube movement. Problems Intubation is often a necessary medical solution which creates various nursing problems. Airway sensory nerve stimulation causes a cough reflex, involving vagal afferent pathways, the cough centre and motor nerves of the diaphragm, abdomen, intercostal muscles and larynx. Coughing is a protective mechanism, removing foreign bodies (including respiratory pathogens) from the airway at up to 100 mph. This reflex can be initiated by oral endotracheal tubes and suction catheters, causing discomfort (antitussive drugs, such as codeine phosphate, can suppress gag reflexes). Many critically ill patients have impaired gag reflexes, causing possible aspiration (including past low-pressure endotracheal cuffs). Impaired cough and swallowing reflexes may cause aspiration of saliva and gastric secretions. Seals are usually incomplete; cuffs often develop slow leaks, usually from external valves, but sometimes from cuff permeability to gases or chemicals. If excessive cuff volumes or pressures are needed, the tube probably needs replacing. While cuff pressure should be sufficient to minimise risks from aspiration, excessive pressure on tracheal epithelium may occlude capillary perfusion causing tracheal ulcers; unlike pressure sores on skin, these are not directly visible. Assessing cuff pressures by squeezing the external balloon is unreliable, but commercially available manometers are available and reliable, and so nurses should, as part of their individual accountability, check cuff pressures at least once each shift, and whenever cuff volume is changed. Nasal intubation and tracheostomy prevent hypersalivation, but tracheal secretions may still accumulate. Like cuff pressure sores (above), pressure from tubes can damage any surrounding tissue (lips, gums, nostril). Sympathetic nervous stimulation from intubation and suction initiates stress responses (see Chapter 3); suction-induced stress responses can cause intracranial hypertension (Brucia & Rudy 1996). Direct vagal nerve stimulation (anatomically close to the trachea) can cause bradycardic dysrhythmias and blocks, especially during intubation. Patients’ inability to speak due to intubation through their vocal cords should be explained. Humidification Nasal epithelium has a rich venous supply covering the nasal conchae; air turbulence maximises exposure for heat and moisture exchange, inspired air normally reaching body temperature just below the carina (Jackson 1996); thus the human airway (a) warms, (b) moistens, and (c) filters inspired air. Endotracheal intubation bypasses these normal physiological mechanisms, necessitating artificial replacement. Hot air transports more water vapour than cold air and so fully saturated room air/gas (100 per cent relative humidity) will not be fully saturated once warmed to body temperature. Gas not fully saturated absorbs moisture from airway surfaces, causing dehydration, making mucus more viscid. Viscid mucus increases: ■ risk of chest infection ■ risk of airway encrustation/obstruction ■ airway resistance and work of breathing ■ surfactant dysfunction Gas should therefore be heated and fully saturated exogenously; tracheal gas temperature should be 32–36°C. Heated water baths provide an ideal medium for bacterial incubation, particularly pseudomonas. Water bath humidifiers may cause overhumidification, mucosal burns, hyperthermia and water intoxification (Jackson 1996). Where exogenous heat is used, temperature of inspired air should be continuously monitored. Current dilemmas between humidification and infection control lack an ideal solution. Saline lavage to remove encrusted secretions can cause various problems (discussed below). However pulmonary oedema from increased capillary permeability may limit hydration of critically ill patients. Airway management 43 Suction Intubation bypasses non-specific mucus and cilial defences, while impaired cough reflexes from critical illness, antitussives and sedation, enable accumulation of lower respiratory tract secretions, reducing/obstructing airway patency (increasing work of breathing) and providing media for bacterial growth. Endotracheal suction can remove accumulated secretions, but can also cause: ■ infection ■ trauma ■ hypoxia ■ atelectasis Post-discharge surveys consistently identify patient anxiety and discomfort from suction (e. Puntillo 1990), and so it should never be a ‘routine’ procedure (Ashurst 1997); nurses should evaluate benefits against dangers. The changes made in endotracheal suction practice in the 1980s necessitate caution when reading older literature. Indications for suction include: ■ rattling/bubbling on auscultation ■ sudden increases in airway pressure ■ audible ‘bubbling’ from the back of the throat ■ sudden hypoxia (e. Disconnecting ventilation (inevitable unless closed-circuit suction systems are used) causes arterial desaturation, especially when patients are dependent on high levels of oxygen; preoxygenating all patients (3–5 minutes of 100 per cent oxygen) minimises risks.