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Authentic presence order vardenafil 10 mg otc, for me purchase vardenafil 20 mg otc, removes all physical boundaries to my coming to know other discount vardenafil 20 mg. It is a feeling of inter- connectedness with the patient that reverberates beyond the room discount vardenafil 20mg without a prescription,city discount vardenafil 10 mg visa,state,country,world,and galaxy. The first three basic assumptions inherent in nursing as caring facilitate the lived experience of authentic pres- ence in this moment. The assumption that this person is a caring person by virtue of her humanness, complete in that moment, gave me the courage to enter into authentic presence to come to know her as a complete, car- ing person in that moment. As the moment unfolded, our mutual trust enhanced and supported who we were as we lived and grew in that caring encounter. The patient’s need to share with me a special gift was validation that she felt it, too. As the patient demonstrated in the words of her song, she knew that her physical existence was coming to an end and she was not afraid. There was a mutual knowingness that was unspoken, even without the lab work or biopsies. Her lack of fear and her courage allowed her spirit to soar free in the open sky, giving me a glimpse of the spiritual existence. Empirical knowledge is the information that is organized into laws and theories to describe, explain, or predict phenomena. Based in the sciences, it is our understand- ing of anatomy and physiology, diagnostic processes, and treatment regimens. For me, it is the concrete form of the foundation upon which my practice is built. The sixth assumption of nursing as caring is that nursing is both a discipline and a profession. The scientific evidence that lends theory-based knowledge to our profession gives us the diagnostic reasoning we need to address the physical needs that people have. In this particular situation, the laboratory findings confirmed that which we knew personally. Oftentimes the bereaved loved ones need a diagnosis to help cope with the grief of losing a family member. This brings us to ethical knowing—the patience and compassion to be with grieving family members when they are not ready to let go of a loved one who is ready to die. Ethical knowing is also the recognition that these family members are caring persons as well, coping in the only way they know how, through their experiences. Patience is needed to allow other to come to know hope in the moment a loved one is diagnosed with a terminal illness. Hope for a spiritual ex- istence beyond this world was revealed to me in this nursing situation. Each of these patterns of knowing—aesthetic, personal, empirical, and ethical—is borrowed from Carper (1978). They serve as conceptual tools to help us understand and implement the theory of nursing as caring. Broad Application for Advanced Practice Nursing: Summary Nursing as caring provides a theoretical perspective with an organizing framework that guides practice and al- lows for the generation of new knowledge. In addition, it lends a methodological process to define, explain, and verify this knowledge. Nursing as caring guides the use of nursing knowledge and information from other disciplines in ways appropriate to nursing. Through the application of this theory, I have come to know new possibilities for nursing practice. I believe now more than ever that, with the advancing roles of nurses, we need to be clear on what it is that we do that is different from other practitioners. As nurse practitioners continue to be lumped into categories with other midlevel practitioners, we need to demonstrate to our patients that our profession was born of a need from society, a need that only nurses can fill. If there is no call to nursing, our profession will dissolve into the sea of midlevel practitioners. To ensure that our prac- tice maintains its identity, the practice must be built upon research-based nursing theory.

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Drug particles don’t have enough energy to go against the natural flow without help cheap 10 mg vardenafil with mastercard. Help comes from an enzyme or protein carrier that transports drug parti- cles upstream across the membrane and into the plasma purchase vardenafil 20mg on-line. Pinocytosis Pinocytosis is the process of engulfing the drug particle and pulling it across the membrane purchase 10 mg vardenafil with visa. This is similar to how you eat an ice pop by engulfing a piece of it in with your mouth and swallowing it generic 10mg vardenafil amex. How long the drug will be effective and how much drug is needed depends on the route of administration vardenafil 20mg on-line, the dose of the drug, and the dosage form (tablet, capsule, or liquid). The absorption rate of a drug is influenced by a number of factors that might increase or decrease the rate, This is similar to how more gasoline is used to drive at faster speeds. Absorption is affected by many factors that include pain, stress, hunger, fasting, food, and pH. Hot, solid, fatty foods can slow absorption such as eating a Big Mac before taking medication. During exercise, circulation to the stomach is diverted to other areas of the body and drug absorption is decreased. Circulation Blood flow to the site of administration of the drug will help increase the rate of absorption. An area that has a lot of blood vessels and good circulation will help absorb the drug quickly and circulate it to the intended site. When a patient is in shock and has a low blood pressure due to decreased circulation (blood flow) drugs may not be absorbed very quickly. Route of Administration The rate at which drug particles are absorbed is determined by the amount of blood vessels there are in the area where the drug is administered. For example, a drug is absorbed faster in the deltoid (arm) muscle than in the gluteal (butt) muscle because there are more blood vessels in the del- toid muscle. This additional step causes water- soluble drugs to be absorbed more slowly than fat-soluble drugs. If a high concentration of the drug is given, it will tend to be absorbed more rapidly. Sometimes larger (loading or priming) doses of a drug may be given that will be more than the body can excrete. After the first large dose, small maintenance doses will help keep the therapeutic effect. Drugs can be processed when they are manufactured to add other ingredients that will help or hinder absorption. For example, hydrochloric acid in the stomach destroys some drug particles before it can pass through the membrane and into the bloodstream. The percentage of a dose that reaches the blood stream is called the bio- availability of a drug. Typically, between 20% and 40% of drugs that are admin- istered orally reach the blood stream. This is called the first pass effect and is the beginning of the metabolism of a drug that is given orally. Sometimes very lit- tle of the drug remains available for a therapeutic effect after the first pass. Only drugs administered intravenously have a 100% bioavailability because they are directly injected into the vein. Pharmaceutical manufacturers must consider bioavailability when determin- ing the dose for a drug. The percent of active ingredient in a dose is referred to as the drug concentration. These are primary loading— a large concentration that is used to achieve a fast therapeutic effect such as the first dose of an antibiotic, and maintenance dose—a typical concentration of the drug that is used to provide an ongoing therapeutic effect such as subsequent doses of an antibiotic. These are referred to as “free” drugs because they are not bound to any receptor sites. These drug–protein complexes decrease the concentration of free drug in the circulation. The drug molecule is released from the protein and it becomes free drug and can be absorbed for use. Drugs affect areas of the body with good blood supply first, such as the heart, liver, kidney, and brain and then flow to areas with less blood supply, such as muscles and fat. Drugs accumulate in an area of the body and form a reservoir by binding to tissues.

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It was largely con- An estimated 3 order vardenafil 20mg with visa,154 order 20mg vardenafil,000 children were reported to sidered a parent’s prerogative to do whatever he or she child protective service agencies as alleged victims of wanted with their child buy 10 mg vardenafil otc. This means that 45 children out of and buy vardenafil 20 mg without a prescription, seemingly cheap vardenafil 10 mg amex, the prevalence of child abuse have be- 1,000 were reported as abused or neglected and 14 con- come widespread. On average, three number of child abuse cases indicates increased occur- children died each day in the United States from abuse or rences of abuse or increased public awareness that en- neglect in 1997. These figures represent substantiated cases, four types, although many psychologists dispute the use- meaning they were investigated by child protection ser- fulness of doing so. Like any statistics on child abuse, these must be considered incomplete, since not all cases of abuse are reported. Telephone: toll-free (800) 422-4453 Still, newly arrived immigrants not yet acculturated •National Coalition Against Domestic Violence Telephone: (303) 839-1852 in the United States may, to their surprise, face social service intervention for their cultural practices toward • National Council on Child Abuse and Family Violence children, deemed as child abuse in the United States. Physical abuse does appear more frequently • National Runaway Switchboard in poor families. The possibility of abuse should be investigated if a child shows a number of these symptoms, or any of them to a marked degree: Sexual Abuse Being overly affectionate or knowledgeable in a sexual way inappropriate to the child’s age Medical problems such as chronic itching, pain in the genitals, venereal diseases Other extreme reactions, such as depression, self-mutilation, suicide attempts, running away, overdoses, anorexia Personality changes such as becoming insecure or clinging Regressing to younger behavior patterns such as thumb sucking or bringing out discarded cuddly toys Sudden loss of appetite or compulsive eating Being isolated or withdrawn Inability to concentrate Lack of trust or fear someone they know well, such as not wanting to be alone with a babysitter Starting to wet again, day or night/nightmares Become worried about clothing being removed Suddenly drawing sexually explicit pictures Trying to be “ultra-good” or perfect; overreacting to criticism Physical Abuse Unexplained recurrent injuries or burns Improbable excuses or refusal to explain injuries Wearing clothes to cover injuries, even in hot weather Refusal to undress for gym Bald patches Chronic running away Fear of medical help or examination Self-destructive tendencies Aggression towards others Fear of physical contact—shrinking back if touched Admitting that they are punished, but the punishment is excessive (such as a child being beaten every night to “make him/her study”) Fear of suspected abuser being contacted Emotional Abuse Physical, mental, and emotional development lags Sudden speech disorders Continual self-depreciation (“I’m stupid, ugly, worthless, etc. It is also possible that a child may show no outward signs and hide what is happening from everyone. Even with such reporting bias, cially, abused children show difficulty in developing however, poverty seems strongly linked to abuse. Child abuse is also linked to parental use of alcohol Within the home, abused children are more disrup- or other drugs. Several studies conducted during the tive and aggressive, frequently viewed by their parents as 1970s confirmed that nearly 70 percent of substantiated defiant and noncompliant. The same the parents’ lower threshold of tolerance for children’s child cues triggers more upset in abusive parents than in noncompliance. Most abusers are likely to have been As adolescents, abused children are more likely to be abused themselves and generally resort to violence to in contact with the juvenile justice system than nonabused cope with life stressors. Their abusive actions can be children of comparable family constellation and income seen as subconscious reactions to an array of stressful as- level. Many of these children are labeled “ungovernable” pects of parenting, including disappointment in the gen- for committing offenses such as running away and truan- der or appearance of a child; a jealous reaction to the at- cy. A higher proportion of abused than nonabused delin- tention a child diverts from themselves; an attempt by quent youth are also involved in crimes of assault. Pedophiles often have a history of being abused themselves, and abusing other Over the last several years, many consider the num- children seems to be triggered by increased life stressors, ber of child abuse reportings to be at epidemic levels. Many find the re- occur due to cumulative neurological damage or due to ports a reflection of a sexually disturbed society, while inadequate stimulation and uncertainty in the child about others believe that increased reporting is the result of sen- the learning environment and the absence of positive sationalist media accounts, celebrity pronouncements parental interactions that would stimulate language and about their own abuse, and over-zealous therapists who motor processes. These delays, in concert with their par- too readily suggest to patients that episodes of sexual ents’ higher-than-normal expectations for their children’s abuse may lay at the heart of their other problems. A coercive cycle frequently devel- peatedly tortured by friends and family members in ops where parents and children mutually control one an- elaborate Satanic ceremonies often involving human other with threats of negative behavior. Writing in The Journal of School-aged children who are abused typically have Psychohistory in 1994, psychoanalyst David Lotto re- problems academically with poorer grades and perfor- ported that at a recent convention of the American mance on standardized achievement tests. Studies of Psychological Association, 800 therapists reported that abused children’s intellectual performance find lower they were currently treating cases of ritual abuse. Abused children also toward dis- researcher David Finkelhor found that as many as 13% tractibility and overactivity, making school a very diffi- of child abuse allegations occurring at day care centers cult environment for them. Stanley Hall, the “father of child psychology their abuse occurred, and yet no trace has ever been in America,” publishes The Contents of Children’s found of such a construction. Putting aside the current controversy over the preva- 1914 John Broadus Watson publishes his most impor- lence of child sexual abuse in this country, no one dis- tant work, Behavior—An Introduction to Com- putes that sexual abuse does in fact occur and takes a parative Psychology. Sexually abused chil- 1926 Jean Piaget publishes The Child’s Conception of dren may still be preoccupied in adulthood with events, the World, followed ten years later by The Orgin trying to understand and repair the damage. Sexual abuse, like severe physi- 1934 Arnold Gesell publishes An Atlas of Infant Behav- cal and emotional abuse, can lead to other psychological ior, followed by Child in the Culture of Today (1943), The Child from Five to Ten (1946), and disorders as well, such as depression, mood disorders, Child Development (1949). In this work, Darwin advanced Interview with National Committee for the Prevention of Child the hypothesis that each individual’s development from Abuse, April 17, 1996. Child development Berry Brazelton, child development has been studied and written about to better understand of children in order The study of the sequential physical, cognitive, to promote their well-being during the various stages of emotional, and social changes a child undergoes childhood, and to help them mature into healthy adults. Freud developed many theories about the enormous The first detailed scientific study of child development influence of childhood experiences on adult behavior was probably Charles Darwin’s Biographical Sketch of and also proposed a five-stage chronological model of an Infant (1877), based on a log he had kept on the devel- childhood psychosexual development. Next comes the phallic stage (3 to 7 years), during Lawrence Kohlberg’s work on the development of which a child experiences and resolves the Oedipal crisis moral reasoning approaches childhood from a different and assumes his or her sexual identity.

Only 27 rapes occur within the context of a romantic relationship purchase vardenafil 10mg without prescription, percent of the women identified themselves as rape vic- and more than half the time the assault takes place in the tims cheap 10 mg vardenafil mastercard, and five percent reported the rapes to police buy vardenafil 20 mg mastercard. 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 vardenafil 20 mg with amex. A group therapy approach in which clients act out their problems to gain new insights and achieve emotional catharsis purchase 10mg vardenafil. A powerful and destructive phenomenon wherein a person or group of people are blamed for what- ever is wrong. Too much or too little arousal can produce effect long-lasting behavioral changes. Thus, usefulness of encounter groups is limited to psychologi- appropriate degrees of sensory deprivation may actually cally healthy individuals, as the intense and honest na- have a therapeutic effect when arousal levels are too high. Sensory deprivation experiments of the 1950s have shown that human beings need environmental stimula- tion to function normally. In a classic early experiment, Separation anxiety emerges according to a develop- college students lay on a cot in a small, empty cubicle mental timetable during the second half year in human nearly 24 hours a day, leaving only to eat and use the infants. They wore translucent goggles that let in light maturation, rather than the onset of problem behaviors. The continuous hum kibbutzim, and Guatemalan Indians display quite similar of an air conditioner and U-shaped pillows placed patterns in their response to maternal separation, which around their heads blocked out auditory stimulation. They became disori- that the one-year-old is alerted by the absence of ented and had difficulty concentrating, and their perfor- the parent and tries to understand that discrete event. If it mance on problem-solving tests progressively deteriorat- fails, is created and the child cries. Although Cultural practices have an impact on separation anx- they were paid a generous sum for each day they partici- iety. Infants who remain in constant contact with their pated in the experiment, most subjects refused to contin- mothers may show an earlier onset of separation anxiety, ue past the second or third day. After they left the isola- and possibly more intense and longer periods of reactivi- tion chamber, the perceptions of many were temporarily ty. For example, Japanese infants who are tested in distorted, and their brain-wave patterns, which had ’s Strange Situation show more intense slowed down during the experiment, took several hours reactions to the separation, presumably as a result of cul- to return to. The intensity of the discomfort tural norms prescribing constant contact between mother these volunteers experienced helps explain why solitary and infant for the first several years of life. City of Hope National Medical the normal school experience by impeding the develop- Center. Systems that address personality as a combi- about 40% of children with Tourette syndrome often nation of qualities or dimensions are called trait theories. One was the distinction be- Tourette syndrome whose symptoms interfere with their tween personal dispositions, which are peculiar to a sin- ability to learn in a regular classroom gle individual, and common traits, which can be used for should become familiar with their children’s rights to an describing and comparing different people. While person- individualized education program under Public Law 94- al dispositions reflect the individual personality more ac- 142, the 1975 federal law aimed at insuring an adequate curately, one needs to use common traits to make any education for children with special needs. Allport also claimed that about seven central traits dominated each individual personality (he described Baton Rouge Tourette’s Support Group. Allport was the cardinal trait—a quality so intense that it [Juvenile] governs virtually all of a person’s activities (Mother personal management styles in many American corpo- rations have been linked to the increase in workplace violence, nearly one-fourth of which end in the perpe- trator’s suicide. One type of violence that has received increased at- The high incidence of violence in the United tention in recent years is domestic violence, a crime for States is of great concern to citizens, lawmakers, and which statistics are difficult to compile because it is so law enforcement agencies alike. Between 1960 and heavily underreported—only about one in 270 incidents 1991, violent crime in the U. Estimates of the and over 600,000 Americans are victimized by hand- percentage of women who have been physically abused gun crimes annually. Violent acts committed by juve- by a spouse or partner range from 20 percent to as high niles are of particular concern: the number of Ameri- as 50 percent. Young African American males are partic- by women of all ages, races, ethnic groups, and social ularly at risk for becoming either perpetrators or vic- classes. For white males born in 1987, the ratio is Various explanations have been offered for the high one in 205. Workplace violence may television programs average 10 violent acts per hour, be divided into two types: external and internal. Exter- while children’s cartoons average 32 acts of violence nal workplace violence is committed by persons unfa- per hour.

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