By D. Sibur-Narad. Great Lakes Maritime Academy.

Confidence in major health-care institutions and The practice of nursing occurs in organizations their leaders fell so low as to put the legitimacy of that are generally bureaucratic or systematic in na- executives at risk discount fincar 5 mg with amex. Although there has been much discussion ment to employees buy genuine fincar on line, investment in the worker buy cheapest fincar, fair- about the end of bureaucracy to better cope with ness in pay, and the need to provide good benefits twenty-first-century innovation and worklife were in jeopardy. Health-care systems fell victim to (Pinchot & Pinchot, 1994), bureaucracy remains a the corporatization of the human enterprise. Informal organization or the 2001), currently is being evaluated in terms of is- integration of codes of conduct encompassing sues of patient safety (Page, 2004). Nursing educa- commitment, identity, character, coherence, and a tion is highlighted as a bridge to quality (Long, sense of community was considered essential to the 2003). Since the Institute of Medicine report (Page, successful functioning or the administering of 2004), a resurgence of interest is taking place in the power and authority in the formal organization. What distin- work (Cuilla, 2000; Ray, Turkel, & Marino, 2002) is guishes organizations as culture from other para- replacing the language of downsizing, restructur- digms, such as organizations as machines, brains, ing, mergers, and acquisitions. Cuilla (2000) stated or other images (Morgan, 1997), is its foundation that “[t]he most meaningful jobs are those in which in anthropology or the study of how people act in people directly help others or create products that communities or formalized structures and the sig- make life better for people” (p. Although the nificance or meaning of work life (Ciulla, 2000; traditional work of nurses is defined as directly Louis, 1985). Organizational cultures, therefore, are helping others, contemporary nurses’ work is also viewed as social constructions, symbolically defined by and in the organizational context— formed and reproduced through interaction legal, ethical, economics, technological, and politi- (Smircich, 1985). Urging nurses, physicians, and administrators organizational mission and policy statements. A to find cohesion among organizational phenomena nation’s prevailing tenets and expectations about and body, mind, and spirit integration for the sake the nature of work, leisure, and employment of the patient calls for the reinvention of work (Fox, are pivotal to the work life of people; hence, there is 1994). Incorporating business principles and the an interplay between the macrocosm of a na- “work of the soul” or relational self-organization tional/global culture and the microcosm of specific (Ray, Turkel, & Marino, 2002) means leading in a organizations (Eisenberg & Goodall, 1993). It is a witness cent years, economics has been a potent contestant to the power and depth of reseeing the good of in macro- and microcultures. There is an ever nursing, searching for meaning in life, and finding greater concentration of economic and political new meaning in the complexities of work itself. Identifying professional nurse caring work as woven into the social and economic fabric of na- having value and an expression of one’s soul or tions. As organizations were affected by issues one’s creative self at work replaces the notion of of cost and profit, health-care systems underwent nursing as performing machinelike tasks. Leadership models, which ings and symbols of organizations (Ray, 1981, are fundamentally hierarchical because of the need 1989). Weber (1999) actually predicted that the fu- for order, continue to head the short-lived partici- ture belonged to the bureaucracy and not to the pative movement toward decentralization. Weber, who saw bureaucracy as an still in the hands of a few as global economics and efficient and superior form of organizational the market rule (Korten, 1995). As a result, the con- arrangement, predicted that bureaucratization of cept of bureaucracy does not seem as bad as was enterprise would dominate the world (Bell, 1974; once thought. This, of course, is witnessed by the radical than the business paradigm that focuses on current globalization of commerce. Recent acquisi- competition and response to market forces, subse- tions and mergers of industrial firms and even quently eradicating standards of fairness for health-care systems, especially in the United States, human beings in the workplace. As such, caring is considered by of organization, Britain and Cohen (1980) stated many nurse scholars to be the essence of nursing that, “Like it or not, humankind is being driven to (Boykin & Schoenhofer, 2001; Leininger, 1981, a bureaucratized world whose forms and functions, 1991, 1997; Morse, Solberg, Neander, Bottorff, & whose authority and power must be understood if Johnson, 1990; Ray, 1989, 1994a, 1994b; Swanson, they are ever to be even partially controlled”(p. Although not uni- The characteristics of bureaucracies are as formly accepted, Newman, Sime, and Corcoran- follows: Perry (1991; Newman, 1992) characterized the social mandate of the discipline of nursing as • A division of labor caring in the human health experience. Caring thus • A hierarchy of offices is an influential concept, and the expression “car- • A set of general rules that govern performances ing”in the human health experience emphasizes the • A separation of the personal from the official social mandate to which nursing has responded • A selection of personnel on the basis of techni- throughout its history and encompasses the scope cal qualifications of the discipline (Roach, 2002). Caring, however, is • Equal treatment of all employees or standards of manifested in different and complex ways in the fairness nursing discipline and profession (Morse et al. Various paradigms that en- • Protection of dismissal by tenure (Eisenberg & fold the care and caring ideal exist in nursing. In the past two decades, there has been a call person, society, environment, and health character- for decentralization and the “flattening” of organi- ize the nature of nursing. The simultaneity para- zational structures—to become less bureaucratic digm illuminates the human-environment integral and more participative or heterarchical (O’Grady & nature of nursing. Many firms have begun to hold to paradigm states that what constitutes nursing’s new principles that honor creativity and imagina- reality is the view that the human being is unitary tion (Morgan, 1997). Even nursing has advanced in and evolving as a self-organizing field embedded in a more collaborative or decentralized manner by its a larger self-organizing field identified by pattern focus on patient-centered nursing and more decen- and interaction with the larger whole. Health is tralized control from administration (Long, 2003; considered expanded consciousness, and caring in Nyberg, 1998). Technological/ Although the model demonstrates that the di- Political Physiological mensions are equal, the research revealed that the economic, political, technical, and legal dimensions Legal were dominant in relation to the social and ethi- cal/spiritual dimensions.

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Most epidural hematomas result from blunt trauma to the temporal or temporoparietal area with an associated skull fracture and middle meningeal artery disruption generic fincar 5 mg mastercard. The classic history of an epidural hematoma is a lucent period following immediate loss of consciousness after significant blunt head trauma purchase fincar cheap online. Most patients either never lose consciousness or never regain consciousness after the injury fincar 5 mg on-line. The high-pressure arterial bleeding of an epidural hematoma can lead to herniation within hours after injury. They result from a collection of blood below Trauma Answers 161 (Courtesy of Adam J. In con- trast, the low-pressure venous bleed of a subdural hematoma layers along the calvarium. They may occur either at the site of the blunt trauma or on the opposite site of the brain, known as a contre- coup injury. This causes the ligamentum flavum to buckle into the spinal cord, resulting in a contusion to the central portion of the cord. This injury affects the central gray matter and the most central portions of the pyramidal and spinothalamic tracts. Patients often have greater neurologic deficits in the upper extremities, compared to the lower extremities, since nerve fibers that innervate distal structures are located in the periphery of the spinal cord. In addition, patients with central cord syndrome usually have decreased rectal sphincter tone and patchy, unpredictable sensory deficits. Its hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column. Blood products should be administered if vital signs transiently improve or remain unstable despite resuscitation with 2 to 3 L of crystalloid fluid. However, if there is obvious major blood loss and the patient is unstable, blood transfusion should be started concomitantly with crystalloid adminis- tration. The main purpose in transfusing blood is to restore the oxygen- carrying capacity of the intravascular volume. Fully cross-matched blood is preferable (eg, type B, Rh-negative, antibody negative); however, this process may take more than 1 hour, which is inappropriate for the unstable trauma Trauma Answers 163 patient. Type-specific blood (eg, type A, Rh negative, unknown antibody) can be provided by most blood banks within 30 minutes. If type-specific blood is unavailable, type O packed cells are indicated for patients who are unstable. To reduce sensitization and future complications, type O, Rh-negative blood is reserved for women of childbearing age. Whole blood is not used because the extra plasma can contribute to transfusion associated circulatory overload, a potentially dan- gerous complication. However, if type O, Rh-negative blood is unavailable, then type O, Rh-positive blood should be administered to women. The retroperitoneum can accommodate up to 4 L of blood after severe pelvic trauma. However, the initial and simplest modality to use in a patient in shock from a pelvis fracture is placement of a pelvic binding garment. This device can be applied easily and rapidly and is typically effective in tamponading bleeding and stabiliz- ing the pelvis. However, venography is not useful in managing these patients: even when venous bleeding is localized, embolization is ineffective because of the exten- sive anastomoses and valveless collateral flow. Angiography is indicated when 164 Emergency Medicine hypovolemia persists in a patient with a major pelvic fracture, despite con- trol of hemorrhage from other sources. Since angiography typically takes place in the angiography suite, patients should have a pelvic binding device applied, prior to being transferred to angiography. It may also occur from vascular pathology, such as laceration or thrombosis of the anterior spinal artery. The syndrome is characterized by different degrees of paralysis and loss of pain and temper- ature sensation below the level of injury. Its hallmark is the preservation of the posterior columns, maintaining position, touch, and vibratory sensation. Central cord syndrome (b) is often seen in patients with degenerative arthritis of the cervical vertebrae, whose necks are subjected to forced hyperextension. This is seen typically in a forward Syndrome Neurologic Deficits Anterior cord B/L paralysis below lesion, loss of pain and tempera- ture, preservation of proprioception and vibratory function Central cord Lower extremity paralysis > upper extremity paralysis, some loss of pain and temperature with upper > lower Brown-Séquard Ipsilateral: paresis, loss of proprioception, and vibratory sensation Contralateral: loss of pain and temperature Cauda equina Variable motor and sensory loss in lower extremities, bowel/bladder dysfunction, saddle anesthesia Trauma Answers 165 fall onto the face in an elderly person. Patients often have greater sensorimo- tor neurologic deficits in the upper extremities compared to the lower extremities.

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The clinical scenarios by Jane Roe provide an opportunity for nurses to apply the knowledge acquired in each chapter to a clinical situation buy discount fincar 5mg online. The glossary explains technical terms that are likely to cause problems and the first occurrence of these have been highlighted in the text effective 5mg fincar. Few laws of physics or medical formulae are included unless frequently used in clinical nursing practice discount fincar 5mg with amex. Many chapters identify issues surrounding families; this implicitly includes friends and all other significant visitors. A few chapters include references to statute and civil law; these are usually English and Welsh law, and so readers in Scotland, Northern Ireland and outside the United Kingdom should check applicability to local legal systems. I have tried to minimise errors, but some are almost inevitable in a text of this size; like any other source, this text should be read critically. Although intensive care nursing is younger than most healthcare specialities, it already possesses a wealth of nursing knowledge and experience. I hope this book contributes to further growth of intensive care nursing, and enables readers to develop their own specialist practice. I would also like to thank all the reviewers who read and assisted with comments on the developing typescript: John Albarran, University of the West of England; Kate Brown and Maureen Fallon, Nightingale Institute, King’s College University; Kay Currie, Glasgow Caledonian University; Lynne Harrison and Mandy Odell, University of Central Lancashire. All reasonable efforts have been made to contact the copyright holders of material reproduced in this book. Any omissions brought to the attention of the publishers will be remedied in future editions. I am grateful to everyone at Middlesex University for the support given towards this book, and for the sabbatical leave which enabled me to complete it. I would especially like to thank Sheila Quinn (Senior Lecturer, Middlesex University), who has helped me at so many stages of my career, and who first suggested I should write a textbook. I would also like to thank everyone who has helped develop my ideas, especially past and present staff of the Whittington Hospital and all my past students and colleagues and clinical staff at Chase Farm and North Middlesex Hospital. And of course this book would not have been possible without the encouragement and support of Routledge, in particular Alison Poyner and Moira Taylor. It develops issues that may have been introduced during pre-registration courses, but which can too easily be lost in the technical demands of intensive care. The first chapter therefore explores the values underlying intensive care nursing; the second chapter develops these through outlining two influential moments in psychology. The third chapter examines issues about the environment in which intensive care patients are nursed. The human needs and problems of nursing rituals are explored in the chapters on pain management, pyrexia, nutrition, mouthcare, eyecare and skincare. The next two chapters then explore the extremes of age: paediatrics and older adults. Chapter 1 Nursing perspectives Introduction This book explores issues for intensive care nursing practice, and this first section establishes its core fundamental aspects. To help readers to do this, this first chapter explores what nursing means in the context of intensive care and the following chapter outlines two schools of psychology (behaviourism and humanism) that have influenced healthcare and society. Acknowledging and continuously re-evaluating our individual values and beliefs is part of human growth, so that examining nursing’s values and beliefs within the context of our own area of practice is part of our professional growth. This is something that each nurse can usefully explore and there are a number of published exercises available in this respect (e. Manley 1994), but essentially it means working out a nursing philosophy for oneself. What is meant by this is not some esoteric message hung neatly on a wall and seldom read or practised—such as ‘man is a bio-psycho-social being’—but, rather, simple values which may be more meaningful—such as ‘remember our patients are human’. Care can (and should) be therapeutic, but therapy (cure) without care is almost a contradiction in terms. These units offered potentially life-saving intervention during acute physiological crises, with the emphasis on medical need and availability of technology. As the technology and medical skills of the speciality developed, so technicians were needed to maintain and operate machines. However, the fact that technology provides a valuable means of monitoring and treatment should not allow it to become a substitute for care. For nursing to retain a patient-centred focus, it is the patients themselves and not the machines that must remain central to the nurse’s role. Healthcare assistants (and, potentially, robots) can be trained to perform technological tasks—and are cheaper to employ. Doctor-nurse relationships Ford and Walsh (1994) observed that nurses working in high dependency areas often have good relationships with medical staff. But Ford and Walsh suggest this good relationship is on the terms of the medical staff. For example, nursing’s focus on the emotional costs to intensive care patients may limit the wider recognition of nursing as a profession (Phillips 1996).