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The girl blames her mother for de- priving her of a penis safe tadalafil 10 mg, and desires her father because he possesses one generic tadalafil 20 mg amex. As in the Oedipus complex tadalafil 10mg otc, the girl even- tually represses her incestuous desires and identifies with Influenced by a combination of biological and soci- the same-sex parent (in this case, the mother). Once estab- pecially by feminist critics who reject its assumption that lished, it is generally fixed for life. Girls mature faster than boys, are physically caregiver, which leads to a greater sense of interrelated- healthier, and are more advanced in developing oral and ness in girls, who identify with the mother and go on to written linguistic skills. Boys are generally more ad- reproduce the same patterns of mothering in their own vanced at envisioning and manipulating objects in space. This “reproduc- larger groups and more space than the play of girls the tion of mothering,” being both biologically and sociologi- same age. In spite of conscious attempts to reduce sex cally determined, is at least theoretically open to the pos- role stereotyping in recent decades, boys and girls are sibility of change if patterns of parenting can be altered. The way adults play with infants has been found to proached in different terms by differ based on gender—girls are treated more gently (1927-1987), who formulated the concept of and approached more verbally than boys. As children , the awareness that gender remains fixed grow older, many parents, teachers, and other authority throughout a person’s lifetime. Kohlberg noted that figures still tend to encourage independence, while children are aware of their own gender and the , and exploration more in boys and expressivity, nur- gender of others by the age of three, they do not really turance, and obedience in girls. In reality, people who act silly or respond to instructions to do foolish things do so because they want to. The hypno- tist creates a setting where the subject will follow sug- gestions—but the subject must be willing to cooperate. The subject has control of the process of hypnosis, with the hypnotist simply guiding him or her. In modern times, the first scientist to test mental ability was ,aFrench psycholo- One feature that characterizes the newly developing gist who devised an intelligence test for children in 1905, concept of intelligence is that it has broader meaning based on the idea that intelligence could be expressed in than a single underlying trait (e. Binet created the concept of “mental age,” berg and Gardner’s emergent ideas suggest that any sim- according to which the test performance of a child of av- ple attempt at defining intelligence is inadequate given erage intelligence would match his or her age, while a the wide variety of skills, abilities, and potential that gifted child’s performance would be on par with that of people manifest. Binet’s test was intro- early years of intelligence testing have recurred repeat- duced to the United States in a modified form in 1916 by edly throughout this century. The scoring system of the new test, de- of the relative effects of versus , vised by German psychologist William Stern, consisted the degree to which intelligence can change, the extent of dividing a child’s by his or her chronolog- of cultural bias in tests, and even whether intelligence ical age and multiplying the quotient by 100 to arrive at tests provide any useful information at all. The Wechsler scales nition of intelligence that has currency at any given time replaced the single mental-age score with a verbal scale reflects the social values of the time as much as the sci- and a performance scale for nonverbal skills to address entific ideas. The Stanford-Binet and Wechsler tests (in mains closely tied to Charles Spearman’s ideas, despite updated versions) remain the most widely administered new waves of thinking. Average performance at ror the values of our culture, linking them to academic each age level is still assigned a score of 100, but today’s skills such as verbal and mathematical ability, although scores are calculated solely by comparison with the per- performance-oriented tests exist. Among the general population, gence scales; Wechsler Intelligence Scales scores cluster around 100 and gradually decrease in ei- ther direction, in a pattern known as the distribu- tion (or “bell”) curve. The tests don’t measure many of the qualities necessary for achievement in the world of work, such as persistence, self-confidence, , and interpersonal skills, or the ability to set priorities and to allocate one’s time and effort efficiently. With Arnold Abramovitz, he was the first to encouraged people to stop repeating the same mistakes. He studied They argued that misconceptions, such as “life should be treatments for alcoholism and was one of the first to fair,” lead to depression, anxiety, and feelings of. During his career, Lazarus has treated thousands of By the 1960s, it was clear to Lazarus that the therapy clients, as individuals, couples, families, and groups. He movement he had initiated, utilizing the stimulus-re- is a diplomate of the International Academy of Behav- sponse mechanisms of behaviorist psychology, was too ioral Medicine, Counseling, and Psychotherapy, and he limited for effective psychotherapy. His 1971 book, was elected to the National Academy of Practice in Psy- , laid the foundations for chology in 1982. Lazarus is the author or editor of fif- what became known as cognitive-behavior therapy. He is a recipient of the Distinguished psychology from the American Board of Professional Career Award from the American Board of Medical Psy- Psychology and returned to private practice in Princeton, chotherapists and a fellow of the Academy of Clinical New Jersey. He joined the Rutgers Graduate Margaret Alic School of Applied and Professional Psychology in 1974. As Lazarus examined long-term results in patients who had undergone , he found some inadequacies. In 1975, Lazarus published his first popular self- help book, , with his colleague Allen Fay. His 1977 book, In any group of people, there are those who step for- , described the use of ward to organize people and events to achieve a specific for personal growth. In organized activities, leaders can be designated psychology writings include several books written with and, in informal contexts, such as a party, they may his son, the psychologist Clifford Neil Lazarus. What makes certain people into leaders 1993 book with Allen Fay, is open to debate. See American existential psychoanalyst who popular- ized a humanistic, spiritually based psychology. Cliometric Metatheory: The actuarial approach to empir- ical, history-based philosophy of science See also Meehl Publications, Pro- fessional Information The Psychology of Melancholy. The sequence and age range of the developmental changes associated with puberty can vary widely. Al- though most children begin puberty between the ages of 10 and 12, it can start at any age from 8 to 16. The most obvious determining factor is gender; on average, puberty arrives earlier for girls than boys. Compared to an overall age range of nine to 18 for menarche, the age difference for sisters averages only 13 months and for identical , less than three months. Body weight is a factor as well: puberty often begins earlier in heavier children of both sexes and later in thinner ones. The onset of menstruation, in particular, appears to be relat- ed to amounts of body fat. Girls with little body fat, es- pecially athletes, often start menstruating at a later- than-average age. Over the past 100 years, puberty has tended to begin increasingly early in both sexes (a phe- nomenon called the ). Herman-Giddens of University of North Carolina at Chapel Hill School of Public Health provided evidence that the average age of menarche was declining. Instead of occurring between the ages of 12 and 14, as is typical in the late 1990s, girls’ first menstrual periods commonly appeared be- tween the ages of 15 and 17 in the 19th century. Puber- ty in boys usually didn’t begin until the ages of 15 or 16 (in the late 18th and early 19th centuries, boy sopra- nos in their mid-to-late teens still sang in church least a year after menarche young women’s fertility lev- choirs). Explanations for this pattern have ranged from els are very low, and they are prone to spontaneous evolution to better health, especially as a consequence abortions if they do conceive. In boys, as in girls, the first outward sign of sexual An important aspect of puberty is the development maturation is often light-colored pubic hair around the of. The testes and scrotum bodies during this period, either because they feel they begin to grow, and the scrotum darkens, thickens, and are maturing too early or too late, or because they fail becomes pendulous. About a year after the testes begin to match the stereotyped ideals of attractiveness for to increase in size, the penis lengthens and widens, tak- their sex (i. Girls who mature early have a hard increases, and ejaculations—the male counterpart to time initially because they feel self-conscious and iso- menarche in girls—begin, occurring through nocturnal lated, but they adjust well and even gain in status once emission, masturbation, or sexual intercourse. Some research even sug- from one to three years until ejaculations contain enough gests that girls who mature early may ultimately be sperm for a boy to be really fertile. Those who are already tall and athletic grows and the vocal cords lengthen, his voice drops in junior high school feel better about themselves than (roughly an octave in pitch) and changes in quality. Researchers have though girls’ voices also become lower, the change is linked late physical maturation in boys to the develop- victim’s home. Rape is one of the most underreported crimes in the United States, due to the victim’s fear of With the rise of Nazi Germany, Rank, a Jew, emi- embarrassment, humiliation, or retaliation by the rapist. Teaching at the Penn- Estimates of the percentage of rapes reported to authori- sylvania School of Social Work, he adopted the nickname ties range from 10 to 50 percent. Because of the difficul- “Huck,” after his favorite American book, ty of obtaining a conviction, about two percent of all. Rank and his wife separated in rapists are convicted, and most serve approximately half 1934. A survey conducted in 1987 found that 57 percent of women who have been raped develop post-traumatic Rank has never received full credit for his contribu- disorder. These women may lose their appetite, tions to psychoanalysis and psychotherapy, primarily be- become easily startled, and suffer from headaches, cause of the attacks by Freudians. Many women have difficul- horred the Nazis, in 1939 the psychologist ty maintaining a normal life following a rape, and may labeled Rank’s “will therapy” a Nazi-style phi- repress the experience for an extended period before losophy. Over the past 20 years 1970s when it was resurrected by the psychologists feminist organizations have fought successfully to and , among others, and by writ- change public attitudes toward rape as well as treatment ers such as Anaïs Nin. Efforts have been made to increase the , with writings by Rank and his followers, was sensitivity of police and hospital personnel to rape vic- published biannually from 1966 until 1983. Today, women work, ,was finally published in police officers routinely investigate rape cases. Most states require physical evi- dence of recent sexual intercourse in which the victim most undergo a medical examination within 24 hours of the assault. In recent years, increased attention has been focused on “date” or “acquaintance” rape, a widespread phenom- ena that is particularly insidious because women who are victimized in this way are more likely to blame them- selves and are less likely to seek help or prosecute their Rape is essentially an act of and dominance. A 1987 study of acquaintance rape at 32 col- Although an estimated 15 to 40 percent of American lege campuses sponsored by magazine found that women are victims of rape or attempted rape, men are one in four women surveyed were victims of rape or at- raped as well. Women are more likely to be raped by tempted rape, that most rape victims knew their attack- someone they know; between 50 and 70 percent of all ers, and over half the assaults were date rapes. Only 27 rapes occur within the context of a romantic relationship, percent of the women identified themselves as rape vic- and more than half the time the assault takes place in the tims, and five percent reported the rapes to police. Of the Sigmund Freud mental health psychoanalysis character traits A projective personality assessment based on the subject’s reactions to a series of ten inkblot pictures.

Tis means that forensic odontologists must be capable of using all known evidence collection and comparison modali- ties and select those modalities appropriate for the case in question purchase 10mg tadalafil with mastercard. Tey should employ blinding techniques to inhibit bias and observer efects in all appropriate phases of their work discount tadalafil 20mg overnight delivery. Competent forensic odontologists will seek second or multiple second opinions from other independent cheap tadalafil 2.5 mg with visa, blinded, competent forensic odontologists. Tey will engage in continuous study and research to improve themselves and forensic odontology and recognize and abide by appropriate codes of ethics and conduct. Tey understand the sci- entifc method and use the method in tests and procedures to the greatest extent possible. In February 2009, the National Academy of Sciences Committee released their report titled Strengthening Forensic Science in the United States: A Path Forward. Chapter 5, Descriptions of Some Forensic Science Disciplines, details their surveys of specifc areas of forensic science. Included in that list and beginning on page 5–35 of that chapter is a section titled Forensic Odontology. Te only discussion of any aspect of forensic odontology other than bitemark analy- sis appears in the frst paragraph, “Although the identifcation of humans remains by their dental characteristics is well established in the forensic science disciplines, there is continuing dispute over the value and scien- tifc validity of comparing and identifying bite marks. Tey summarize by stating, “Although the majority of forensic odontologists are satisfed that bite marks can demonstrate sufcient detail for positive identi- fcation, no scientifc studies support this assessment, and no large popula- tion studies have been conducted. Te committee received no evidence of an existing scientifc basis for iden- tifying an individual to the exclusion of all others. Tis in no way absolves forensic dentists from the responsibility to perform research and establish scientifc bases for bitemark analysis. Te authors think that considerable research supported by funding is war- ranted and needed. Bitemark analysis is too valuable to the investigation and adjudication of certain crimes to be abandoned, discounted, or overlooked. Te sci- entifc basis for associating unknown biters to tooth marks or bitemarks must be established. In closed or limited population cases, it may be possible to associate a biter and a bitemark with reasonable dental, medical, or scientifc certainty for that limited population. Bitemarks 365 Forensic odontology certifying bodies must begin to properly test and periodically retest their certifed members for profciency in bitemark analysis. Te requirements for board certifcation in North America, as they relate to bitemark analysis, are inadequate. Receiving board certifcation afer being the principle investigator on one bitemark and co-investigator on another cannot be justifed as sufcient experience. A remarkably modern list of recommen- dations was written as “Suggested Procedure for Future Cases” by Dr. Included at the end of the list was this perceptive and prudent advisory statement, “Perhaps afer the 5th or 6th case a forensic odontologist might have acquired the skill, knowledge and experience necessary properly to assess skin abrasions in bite-marks; lesser mortals will not lose face but will gain in wisdom by humbly sitting at the feet of a forensic pathologist who may have spent a lifetime specialising in this subject. Tey must have commit- ted to continuously study, experiment, and learn, and if called upon to do so, they must have the vision, energy, and courage to make necessary changes. Dental, medical, police and legal aspects of a case in some ways unique, difcult and puzzling. Anatomical location of bitemarks and associ- ated fndings in 101 cases from the United States. Seven hundred seventy eight bite marks: Analysis by anatomic location, victim and biter demographics, type of crime, and legal disposition. Reliability of the scoring system of the American Board of Forensic Odontology for human bite marks. Discussion of “Reliability of the scoring system of the American Board of Forensic Odontology for human bite marks. Spitz and Fisher’s medicolegal investigation of death: Guidelines for the application of pathology to crime investi- gation, xxx. Generating transparent bitemark overlays using a scanner, microcomputer, and laser printer. Accuracy of bite mark overlays: A compari- son of fve common methods to produce exemplars from a suspect’s dentition. Te uniqueness of the human anterior dentition: A geo- metric morphometric analysis. Te use of human skin in the fabrication of a bite mark template: Two case reports. Establishing personal identifcation based on specifc patterns of missing, flled, and unrestored teeth. Over the previous decades, best estimates indicate that somewhere between 20 and 50% of U. Many of the injuries associated with inficted (also termed nonaccidental or intentional) trauma are seen in the maxillo- facial complex. Tese inficted injuries are ofen treated on an immediate or delayed basis by general dentists, specialists within the dental profession, physicians, or ancillary members of the oral health care team. Tis chapter will provide useful information when determining if the facial/dental injuries are accidental in nature or if the trauma is more likely to be the result of nonaccidental trauma. Te key features that are helpful in diferentiating accidental injuries from inficted injuries are: 1. Delayed presentation for care 369 370 Forensic dentistry When presented with injuries such that the history and physical exami- nation suggest the trauma might not be accidental in origin, the oral health care provider should always include inficted trauma in the diferential diag- nosis. Health care providers must remember that all forms of familial and intimate partner violence are interrelated. Since the sequelae of violence afects all age groups—especially those living together—one form of violent behavior cannot be separated from another. Domestic violence and violence within the family—child abuse, spouse abuse, abuse/neglect of the disabled, and elder abuse—are common in Western society. Violent assaults can result in injuries to the developing fetus, children, adolescents, adults, and the elderly; in fact, no age group is free of the potential for violent acts. Te most recent estimates from the Centers for Disease Control and Prevention indicate that approximately 25% of women have been raped or physically assaulted by an intimate partner. More than 40% of women who experience partner rapes and physical assault sufer some form of physical injury. Intimate partner violence can take many forms, to include psychological/ emotional, physical, and sexual abuse. Intimate partner violence can begin in the dating relationship, while cohabitating, while married, when separated or divorced, and can continue into the later years of life. Unfortunately, the violence can ofen result in death, serious physical injury, disfgurement, and emotional injuries. In the United States, child protective services best estimates indicate that there are approximately eight hundred thousand annual cases of child maltreatment. Childhood exposure to abuse, neglect, and parental violence has been associated with risky behaviors, smoking, using illicit drugs, and overeating. Te efects of alcohol, drugs, poor nutrition, and physical trauma are well documented in the professional and lay literature. Assault of the pregnant women can result in a wide range of emotional and physical trauma, includ- ing the potential for injuries that result in death (homicide), perinatal death, low-birth-weight live births, and preterm delivery. In some cases of women reporting being in an abusive relationship, abuse might actually decrease during preg- nancy. A study of dating violence among students in grades 7 to 12 found that physical and psychological violence was 12 and 20%, respectively. Students with poorer grades (mostly Ds and Fs), blacks, non-Hispanics, and students from the northeastern United States were at greatest risk for dating violence and victimization. Te report indicates that: • Approximately one-third of female murder victims were killed by an intimate. Homicides may also result in the murderer taking his or her own life following the violent act that resulted in the death of the intimate partner. It has been reported that 74% of all murder-suicides involved an intimate partner. Of these reported cases, 96% were females killed by their intimate partner, with 75% of these cases occurring within the home. Estimates indicate that the annual medical expense associated with domestic violence is at least $3 billion to $5 billion. Also, businesses are reported to lose another $100 million in lost wages, sick leave, absenteeism, and loss of productivity. Te risk for facial injury was much higher among the domestic violence victims than was seen in other mechanisms of injury. Head injuries were also more common in women victims of intimate partner violence. One published study indicates that 85% of intimate partner violence victims were found to have injuries on more than one area of the body. Te most common sites for injury were the eye, side of the face, throat and neck, upper and lower arms, upper and lower legs, mouth, outside of the hand, back, and scalp. Of importance to dentists, 79% of the injuries were in areas clearly visible (injuries to the head and hands). Abuse knows no age group limitations and is seen in persons of all ages from the very young through the very old (Figures 15. Like other forms of abuse, physical abuse of an elderly individual can appear in many diferent patterns. Other signs are traumatic hair and tooth loss, rope or strap marks indicating physical restraint, multicolored bruises indicating injuries at various stages of healing, and injuries suggesting heal- ing “by secondary intention” (possibly indicating inappropriate or delayed presentation for care).

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An investigation of a nursing system to support tions in all types of care settings generic 10mg tadalafil mastercard, ranging from nutritional self-care in post myocardial infarction patients buy tadalafil 20 mg cheap. Effects of Orem-based to the care of patients in intensive care units nursing intervention on nutritional self-care of myocardial infarction patients order tadalafil 2.5 mg fast delivery. Self-care requirements, self-care capa- ages with all kinds of health-deviation self-care req- bilities and nursing systems in the diabetic nurse manage- uisites and developmental requisites. The influence of health status, burden, and degree of cognitive impairment on the self-care agency and of ambulatory adolescent transplant recipients. Unpublished Nursing services based on Orem’s theory were doctoral dissertation, Wayne State University, Detroit. Predictors of self-care in adolescents with cys- this adolescent population (Norris, 1991). Haas tic fibrosis: A test and explication of Orem’s theories of self-care (1990) also reported on the usefulness of the Self- and self-care deficit. Family caregiver versus nursing assessments practice aimed at meeting the care demands of chil- of elderly self-care abilities. Self-care agency of psychiatric patients: A va- citations appear in the bibliography. Unpublished mas- ter’s thesis, University of Limburg, Maastricht, the Netherlands. The relationship between family as a social sup- port system, health status, and exercise of self-care agency in the Dorothea E. Self-care capabilities in black girls in antic- Deficit Nursing Theory was the foundation ipation of menarche. Health Care for Women International, for developing nursing science, and then de- 13(1), 67–76. Assessing patient self-care for side effects of mented in the literature today supports the cancer chemotherapy—part 1. Patterns of self-care in cancer patients re- ity of the theory for the profession in guiding ceiving radiation therapy. Oncology Nursing the research and scholarship of nurses world- Forum, 24(6), 983–990. Meten van zelfzorg: Verpleegkundige instru- Proceedings of the International Research Congress. Unpublished doctoral dissertation, of patient-environmental factors among nursing home resi- Wayne State University, Detroit. Issues in and validity testing of Finnish version of the appraisal of self- Comprehensive Pediatric Nursing, 13, 253–264. Unpublished doctoral dissertation, Wayne State model for the identification of nursing requirements in a selected University, Detroit. Self-care actions of healthy, middle-aged tic self-care demand and self-care agency in individuals with women to promote well-being. Measuring the self-care practice of children quacy of a health promotion self-care interview guide with and adolescents: Instrument development. Maternal Child healthy, middle-aged, Mexican-American women: A pilot Nursing Journal, 23(3), 101–108. The contribution of personality to adult concept and self-care in children with cancer. International research project to test Nephrology Nurses Association Journal, 18, 45–47, 53. Concept for- of scientific session of the 29th Biennial Convention of Sigma malization in nursing: Process and product (2nd ed. Structuring nursing practice based on Orem’s ated by chemotherapy patients in response to fatigue. Family culture, family resources, depend- Nursing Administration Quarterly, 15(3), 72–78. A case study: Perspectives on a self-care nary artery bypass surgery, a prospective study. Primiparas’ prenatal concern for learn- effects: A programme of inquiry within Orem’s self-care ing infant care. Nursing assessment for risk of homicide Dutch version of the appraisal of self-care agency scale: with battered women. Self-care actions taken by older adults for in- care agency in people beginning a weight loss program. Response to “Predictors of children’s self- of elderly client and nurse perceptions of the clients’ self-care care performance: Testing the theory of self-care deficit. Perceptions of chemotherapy: An assessment of nursing interventions— self-care in Sweden: A cross-cultural replication. Measuring informational intervention for chemotherapy knowledge and self-care behavior. Using self-care the- dational capabilities, and urinary incontinence self-care in ory to guide nursing management of the older adult after hos- women. Appraisal of self-care agency scale: Validity and strument to measure exercise of self-care agency. The nursing preparation of stoma patients for home visits to elderly people by community nurses in the self-care. Assessing and teaching self-care cancer-related fatigue: Refinement and evaluation of Orem’s to youths with diabetes mellitus. Validation of an instrument to measure ex- Conceptualizations and operationalizations. Journal of Adolescent acting variable with self-care agency: Testing a theoretical Health Care, 9, 55–60. Journal of ment to measure mothers’ performance of self-care activities Gerontological Nursing, 17(6), 39–43. A nursing practice theory in three parts, independent elderly: Self-concept affects well-being. Archives of Psychiatric Nursing, 6, ated by chemotherapy patients in response to fatigue. Dependent care, caregiver burden, and tor analysis of Bickel and Hanson’s questionnaire. The health-promoting self-care system concept of women’s self-care developed within Orem’s self-care model: Directions for nursing research and practice. Journal deficit theory: Instrumentation, psychometric evaluation and of Advanced Nursing, 15(10), 1162–1166. Malinski Introducing the Theorist Introducing the Theory Separate Theories Implicit in Science of Unitary Human Beings Summary Bibliography Introducing the Theorist guides practice to promote health and well-being for humankind. Rather, it is the use of nursing knowledge tists, was a staunch advocate for nursing as a basic for human betterment” (Rogers, 1994a, p. She believed that the art of practice could Rogers identified the unitary human being and be developed only as the science of nursing evolved. She repeatedly need to differentiate skills, techniques, and ways of emphasized the need for nursing science to encom- using knowledge from the body of knowledge that pass beings in space as well as on Earth. Rogers’ Science of Unitary Human Beings 161 this visionary who introduced a new worldview to (1964), and the landmark An Introduction to the nursing? From 1963 to Martha Elizabeth Rogers was born in Dallas, 1965 she edited Nursing Science, a journal that was Texas, on May 12, 1914, a birthday she shared with far ahead of its time; this journal offered content on Florence Nightingale. Her parents soon returned theory development and the emerging science of home to Knoxville, Tennessee, where Martha and nursing plus research and issues in education and her three siblings grew up. Rogers spent two years at the University of Along with a number of nursing colleagues, Tennessee in Knoxville before entering the nursing Rogers established the Society for Advancement in program at Knoxville General Hospital. Among other issues, this group attended George Peabody College in Nashville, supported differentiation in education and practice Tennessee, where she earned her bachelor of sci- for professional and technical careers in nursing. Recognizing the gree in nursing who passed the traditional boards need for advanced education, she took a break dur- (Governing Council of the Society for Advance- ing this period and returned to academia, earning ment in Nursing, 1977, 1994). Her theoretical ideas ap- earning a master’s of public health and a doctor of peared in embryonic form in her two earlier books science degree from Johns Hopkins University in and were fleshed out in the 1970a book, then re- Baltimore, Maryland. She articulated the need for a “valid bac- education, and professional and political issues in calaureate education” that would serve as the base nursing. Such a program, she believed, required five years of study in theoretical content in nursing as well as liberal Introducing the Theory arts and the biological, physical, and social sciences. At the doctoral level, Rogers opposed the Human Beings has been described by Malinski and federally funded nurse-scientist doctoral programs Barrett (1994). This chapter presents the science in that prepared nurses in other disciplines rather its current form and identifies work in progress to than in the science of nursing. Rogers (1994b) cautioned that, al- environment, both identified as energy fields” though traditional modalities of practice and (p. This perspective ence creatively in order to develop innovative new necessitates a new worldview, out of which emerges modalities and research approaches that would the Science of Unitary Human Beings, “a pandi- promote the betterment of humankind. It has been available in Rogers (1992) identified four fundamental postu- print with some revisions in language since 1986 lates: (Madrid & Winstead-Fry, 1986; Malinski, 1986; • energy fields, Rogers, 1990a, 1990b, 1992, 1994a, 1994b). Rogers • openness, (1992) described the evolution from older to newer • pattern, and worldviews in such shifting perspectives as cell the- • pandimensionality, formerly called both four- ory to field theory, entropic to negentropic universe, dimensionality and multidimensionality. She pointed In their irreducible unity, they form reality as experienced in this worldview. Rogers (1990a, In a universe of open systems, energy fields 1994a, 1994b) defined the energy field as “the fun- are continuously open, infinite, and inte- damental unit of the living and the non-living,” gral with one another. She identified two energy fields of are continuously open, infinite, and integral with concern to nurses, which are distinct but not sepa- one another. Change that is predictable, brought rate: the human field, or unitary human being, about by a linear, causal chain of events, gives way and the environmental field.

Nutritional assessment Nutritional needs in critical illness should be carefully assessed to prevent knee-jerk reactions buy tadalafil 2.5 mg online. Simple measurements (anthropometry) include: ■ height ■ weight ■ mid-upper-arm circumferences (low=overall weight loss) ■ triceps skinfold thickness (low=significant loss of fat stores) ■ mid-arm muscle circumference (=protein depletion) As half the body fat stores are subcutaneous discount tadalafil 10 mg visa, measuring skinfold thickness (e purchase 2.5mg tadalafil visa. However gross oedema and deceptive increases in body weight may mask muscle atrophy (Sav 1997). But metabolic analysers are expensive, and inaccurate with high oxygen concentrations, acidosis and haemofiltration (Adam & Osborne 1997). Plasma albumin indicates protein synthesis (Say 1997), but hypoalbuminaemia in critically ill patients is multifactorial. Periodic urinalysis is cheap, simple and quick, and so although the causes of abnormalities may be unclear, it provides a means both to detect problems and monitor progress. Implications for practice ■ nutrition benefits from multidisciplinary team approaches; bedside nurses can usefully coordinate care ■ enterai feeding is usually preferable ■ if nasogastric feeding fails, lower gastrointestinal tubes should be considered ■ feed regimes should be individually assessed ■ feed regimes should be fully completed, benefits (and problems) being monitored ■ diarrhoea is rarely caused by nasogastric feeding, so is not an indication to stop feeds Summary Feeding critically ill patients remains problematic, yet it is fundamental to their recovery. Nutritional needs and benefits are often less obvious than those of other major systems, but this chapter has included various noninvasive ways to assess nutritional needs. Further reading Although much is written on nutrition, material does date quickly. Verity (1996b) and Say (1997) offer more recent nursing perspectives, while Schears and Deutschman (1997) is a comprehensive medical article. Methany (1993) presents a rigorous literature review of nasogastric Intensive care nursing 86 nutrition; Kennedy (1997) contains useful material on enterai feeding, although does overstate some aspects. Clinical scenario Sally Day is 35 years old, weighs approximately 60 kg, with an arm span of 1. Her injuries include fractures to lower ribs, pulmonary contusions, and she has a high index of suspicion for damaged spleen. In order to reduce any inter-abdominal pressure on her potentially injured spleen, Sally’s stomach was carefully emptied (decompression of stomach). How can the risks be minimised and Sally’s energy requirements met (in relation to her injuries, fluid management, and metabolic response to injury and starvation). What does exist is largely anecdotal residue from rituals (Hatton- Smith 1994); much research uses inadequate sample sizes: De Walt and Haines’ much- cited 1969 study used one adult (Kite & Pearson 1995), while Nelsey’s (1986) sample size was four patients, one being used for control. The mouth is used to communicate (lip-reading is possible despite intubation, and following extubation, oral discomfort may make speech difficult). The mouth is also associated with intimate emotions (smiling, kissing); patients with, or thinking they have, dirty mouths or halitosis may feel psychologically isolated. Mouthcare should therefore Intensive care nursing 88 ■ maintain hygiene ■ keep the oral cavity moist ■ promote comfort ■ protect from infection ■ prevent trauma ■ prevent dental decay. Oral anatomy is briefly revised, but readers should supplement any aspects they are not familiar with from anatomy texts. Anatomy Unlike all other major body systems, gut stimulation is counterproductive to ‘fight or flight’ responses: parasympathetic nerve stimulation accelerates gut functions, while sympathetic nerve stimulation decelerates them. Placing cotton wool rolls on the main salivary glands can remove excess saliva as effectively (and with less trauma) as endotracheal suction. Sympathetic vasoconstriction and dehydration reduce salivary gland perfusion, making saliva viscous and mucin-rich (dry mouths are familiar from ‘fight and flight’ responses). Endogenous sympathetic stimulation from stress may be compounded by exogenous catecholamines (adrenaline/noradrenaline). Teeth have four layers: ■ enamel (brittle, acellular, irreparable) ■ dentin (bulk of tooth, mainly collagen) ■ cementum (covering roots, mainly collagen) Intensive care nursing 90 ■ pulp (central part of tooth, mainly collagen; unlike other layers, contains blood vessels and nerves (Murray et al. Gingival crevices are especially susceptible to plaque formation (Mallett & Bailey 1996). Accumulated plaque calcifies into calculus or tartar, disrupting seals between gingivae and teeth. Gingivitis (sore, red and bleeding gums) occurs within ten days of plaque formation (Kite & Pearson 1995). Plaque is not water soluble, so that mouthwash solutions do little to remove plaque; antibacterial mouthwashes (e. Oral neglect enables bacteria to multiply around teeth and dissolve bone (peritonitis/periodontal disease). Infection is usually bacterial (Clarke 1993)—common organisms including Staphylococcus aureus and Pseudomonas sp. Candidiasis, the most common fungal infection (susceptible to nystatin), can be recognised by white spots (Clarke 1993). Herpes simplex, the major oral virus (susceptible to aciclovir cream), creates sores and cysts around the mouth and lips (Clarke 1993). Oral secretions accumulate rapidly when swallowing reflexes are impaired (experienced during almost any dental examination). Oral suction can remove much accumulated saliva, debris and microorganisms, but removal is almost inevitably incomplete. Oral decontamination (similar to selective digestive decontamination—see Chapter 15) may prevent spread from oral to respiratory infection. Assessment Oral assessment should include each aspect of the oral cavity: ■ lips ■ gums ■ teeth ■ tongue ■ hard palette ■ soft tissue ■ salivary production ■ evidence of any infection ■ evidence of any cuts/purpura/blood These should be assessed against risk factors from ■ overall condition ■ underlying pathology ■ treatments (including effects of drugs) Although assessment should be individualised to each patient, assessment tools can provide a useful structure. Holmes and Mountain (1993) found problems with three tools tested with oncology patients. This tool is potentially useful, but his article is not a research report of the tool’s effectiveness, and the tool requires subjective evaluations (e. Treloar (1995) presents useful criteria (salivary flow, plaque, gingiva, lip Table 10. Oral assessment necessitates viewing the oral cavity, so tongue depressors and torches are helpful (Jenkins 1989). As part of universal precautions (see Chapter 40), protective gloves should be worn. Mouthcare 93 Lotions and potions Many mouthcare solutions and other aids have been marketed, most with little support beyond custom and practice. Few remove or prevent plaque, or provide other significant benefits, and many leave unpleasant tastes (nurses can understand patients’ experiences by tasting non-prescription products themselves). Lemon-flavoured swabs (introduced to stimulate salivary production) can decalcify teeth (Crosby 1989). Glycerine is hypertonic, so causes dehydration and reflex salivary gland exhaustion (Crosby 1989). Insufficient dilution of chemicals such as sodium bicarbonate and hydrogen peroxide can cause mucosal burns (Tombes & Galluci 1993); even chlorhexidine rinse can alter oral flora and stain teeth black. Some mouthwashes are antibacterial: pharmacists can advise which solution is best for each patient. Foam sticks can moisten mucosa between cleaning, but do not remove debris from surfaces or between teeth (Pritchard & Mallett 1992), and so plaque accumulation continues (Pearson 1996). As hard sticks cause oral trauma, they should be used carefully and (when possible) with good light. Toothbrush Toothbrushes (with or without toothpaste) remain the best way to clean patients’ teeth, loosening debris trapped between teeth and removing plaque from tooth surfaces (Pritchard & Mallett 1992). The technique reflects that of brushing one’s own teeth: brush away from the gums to remove, rather than impact, plaque from gingival crevices. Manipulating toothbrushes in other people’s mouths, especially when orally intubated, can be difficult; smallheaded multitufted toothbrushes, with soft, small, nylon heads and hollow-fibred bristles, are best for brushing the teeth of others (Pritchard & Mallett 1992; Jones 1998). Pritchard & Mallett (1992) and Jones (1998) recommend the ‘Bass’ method: placing the toothbrush at 44° to the gingival margin, using very small vibratory movements so bristles reach subgingivally to collect and remove plaque. With trismus (limited mouth opening), an interspace toothbrush will remove plaque (although not clean between teeth) (Pritchard & Mallett 1992). Gentle brushing of gums and tongue can also be useful with endentitious patients (Day 1993). Toothpaste should be removed with mouthwashes (Jenkins 1989) and gentle suction, as residual toothpaste can cause further drying of the mucosa. Vigorous brushing may cause bleeding, especially if patients have coagulopathies (e. Intensive care nursing 94 Lips Lips are highly vascular, with sensitive nerve endings, and are even more closely associated with communication (e. Lipcare can therefore prevent drying and cracking, while providing psychological comfort. Dental decay from plaque and debris occurs after one day (Pritchard & Mallett 1992), and so care should be performed at least daily (Treloar 1995; Burglass 1995), but comfort (e. Pressure sores Any body surface area is susceptible to pressure sore development (see Chapter 12). Endotracheal tubes and tracheostomies place pressure on various tissues, including the mouth and nose. Sores are especially likely when tubes rest on gingival surfaces rather than teeth (Liwu 1990); sides of lips are particularly susceptible to sores. The loosening and moving of tapes and tubes relieves prolonged pressure (Clarke 1993). Dentures Intubation and impaired consciousness normally necessitates removal of any dentures, but property should be checked on admission so that dentures are not lost. Nursing records should include whether patients normally wear partial or complete dentures, and relevant care. Like patients’ own teeth, dentures are easily damaged, warping easily, particularly if left dry or cleaned in hot water (Clarke 1993). As dentures containing metal may corrode, Jones (1998) suggests that they should be immersed for just 20 minutes, although this contradicts recommendations (Crosby 1989; Clarke 1993) that they should be left soaking in cold water. Room-temperature water is a medium for bacterial growth, and should be changed daily (Clarke 1993).

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