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We also initiated a modalities are beneficial vasotec 10 mg fast delivery, while others are ineffec- portfolio of investigator-initiated research vasotec 10 mg with amex. Awards scientific information or sufficient maturation of totaling $8 million each over five years were made the science vasotec 5 mg free shipping. This is illustrated by our support of a study of mit us to develop innovative pilot projects in areas an approach advocated by Dr. Gonzalez treats cancer patients with dietary where possible, on studies involving minority and supplements, including pancreatic enzymes, mag- underserved populations. Preliminary data from nesium citrate, papaya extracts, vitamins, miner- this research will serve as the basis for more defin- als, trace elements, and animal glandular products, itive clinical trials. Cancer patients for longing life expectancy for those suffering from whom a cure is not an option face not only death, pancreatic cancer. Given that conventional regi- but also the diminution of quality of life and mens for this type of cancer only moderately pro- intractable pain. Perhaps as many as 70 percent of long life, there is sufficient argument from a public these cancer patients are seeking complementary health standpoint to evaluate the regimen in a and alternative therapies to expand their end-of- more rigorous fashion. A second trial will native remedies for centuries, little is known about examine safety and efficacy of shark cartilage in how they work. Acupuncture for osteoarthritis pain—the range of motion, as well as the impact of lumbar National Institute of Arthritis and Muscu- spinal manipulation on posture. Despite the growing the research base through collaborative research body of literature that addresses the clinical effects and outreach to scientists and clinicians. More than one million tigators to join us in exploring how acupuncture people in the U. Potential areas of research include the basic in approximately 10 million treatment visits biology and biochemistry of acupuncture, its annually. Acupuncture is administered by a vari- effects at the cellular level, its effects upon body ety of health care providers ranging from conven- systems (such as the immune and nervous sys- tional physicians to Traditional Chinese Medicine tems), and genetic factors that correlate with practitioners. Currently, there is consider- has received an increasing amount of attention able use of acupuncture for the management of recently due to its effect on pain management. As illustrated by investigation include various forms of manual the effects of St. However, little reliable research-based data is ment and prevention of a number of conditions. John’s wort for depression, about the use of botanicals simultaneously with Ginkgo biloba for improved memory, and saw pal- over-the-counter and prescription drugs. For instance, recent increase our knowledge of the mechanisms of studies suggest that St. This been associated with benefits such as preservation phenomenon has also been observed with certain of cardiovascular, skeletal, genitourinary, and cogni- oral contraceptives and drugs that prevent rejection tive health. Soybeans are known National Center for Complementary and Alternative Medicine 97 to be rich in naturally occurring compounds with the number of Americans suffering from asthma. This study would determine the safety and the most significant limitation is the lack of stan- efficacy of magnesium in different subpopulation dardized products worthy of in-depth study. However, tions, emphasizing the use of traditional and folk no conclusive studies have been conducted in medicine among immigrant populations and the humans. We will also con- ing, making awards at the institutional level, as tinue to create opportunities for minority scientists well as to individuals. It integrates or rejects approaches Research training is also an important component based on scientific evidence. For example, will help treat or prevent many of the diseases that willow tree bark is a remedy for arthritis. Not Native American healing practices Methods for unlike steam baths or saunas, sweat lodges and restoration of health based on the belief that phys- special teas that induce vomiting may be part of a ical and emotional well-being is interconnected healing regimen. Smudging—cleansing a place or with morality, spirituality, and harmonious rela- person with the smoke of sacred plants—is also tionships with the community and nature.

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Forensic pathology can be defned as the subspecialty of medicine devoted to the medical investigation of death order vasotec 10 mg fast delivery. It is one of many components of the modern forensic sciences buy vasotec 10mg amex, and is a subspecialty of the medi- cal specialty of pathology cheap vasotec 5 mg without a prescription. In the United States, training in forensic pathology death investigation systems 41 requires completion of a course of medical study, culminating in a doctor of medicine or doctor of osteopathy degree, completion of three or more years of residency training in anatomic pathology, completion of an accredited year of fellowship training in forensic pathology in an accredited training program (usually a large medical examiner’s ofce), and passage of national certifcation tests in both anatomic and forensic pathology, administered by the American Board of Pathology. Te physician can then use the title of forensic pathologist and is considered board certifed in that feld. Te formation of an academic specialty of forensic pathology owes much to early chairs of forensic medicine established in Europe and Scotland, but the frst endowed chair of legal medicine in the United States was established at the Harvard Medical School in 1937. Forensic pathology was frst recognized as a medical subspecialty in 1959, when examinations were administered and the frst cadre of physicians was certifed as forensic pathologists. Over the years, the medical examiner system has been refned somewhat to include some fairly standard elements. Forensic pathologists working under the direction of a coroner should not be referred to as medical examiners, since the coroner is the actual ofcial imbued with the authority to investigate and certify death, not a physician. In this way, the ofce of medical examiner becomes a professional position, not a political one, and the ofce holder is not concerned with currying favor with an electorate and periodically campaigning for reelection. Te sole authority for investigation and certifcation of deaths in his or her jurisdictional area, and is independent of law enforcement, pros- ecutorial, or judicial agencies. Only a trained and experi- enced physician has the knowledge to obtain and analyze such data and to synthesize a rational cause and manner of death conclusion from it. During the frst half of the twentieth century, medical examiner systems progressively replaced coroner jurisdictions throughout the United States. At this time, the populations of twenty-two states are served solely by medical examiners, eleven by coroners, and seventeen by a combination of medical examiner and coroner systems. Some medical examiner states are under the authority of a statewide medi- cal examiner. For instance, in Texas, justices of the peace perform coroner duties in counties without a medical examiner. For these reasons, it is difcult to efectively categorize medicolegal death investigation systems in the United States, as the various systems ofen have little resemblance to each other. In early times, records of birth and death were kept inconsistently, if at all, but in 1538, clergy in England were required to keep a ledger of births, deaths, and marriages in their parishes. Tis custom of registration persisted for many years, but gradually became a death investigation systems 43 Table 4. Tis change was given further impetus during infectious epidemics of the nineteenth century, when it came to be appreciated that it would be worthwhile to keep track of the numbers of deaths occurring as an infectious contagion progressed. Modern death certifcation is a function of state governments, and all jurisdictions in the United States have a common requirement that the death of a person be ofcially documented, with attes- tation of the cause and manner of death by a physician, medical examiner, coroner, or other ofcial. Te document serving this purpose is referred to as a death certifcate, and requirements regarding its use and fling are set forth by a state department of health, vital records, or equivalent. Standard Certifcate of Death, which is in turn based on World Health Organization recommendations. Many states are also moving toward a standardized digital death registration process that promises to make gathering of demographic and epidemiologic data much simpler and more efective. First, as has been noted above, a developed society has an interest in documenting death investigation systems 45 the birth and death of its citizenry in order to provide for transfer of estates, administration of societal programs, payment of insurance settlements, etc. Te tracking of deaths from an epidemiologic viewpoint allows for better public health surveillance in a society, be it related to epidemic diseases or public safety issues. As all purveyors of television crime dramas are well aware, adequate death investigation and certifcation is required for the criminal prosecution of deaths due to the action or inaction of another person or institution. And fnally, knowledge of the cause and manner of death is ofen of importance in allowing appropriate grieving and closure for the family and loved ones of a decedent.

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For common discourse among health pro- and responses to professional nursing care that fessionals and between nurses and nursing resulted in an instrument that measures patient personnel cheap vasotec 10mg without prescription. Direct measure of outcomes resulting in My vision for the future of nursing is that nursing quality care and cost-effective care; that is order vasotec 5 mg, will provide access to health care for all citizens buy cheap vasotec 10mg on line. One valid and reliable assessment instru- are directed to the right place in the system for ment to assess activities of daily living as a nursing care, medical care, social services informa- basis for goal-setting. For continuity of care within and between tion process will be used by every practicing nurse health-care agencies. Theory of Goal Attainment, and Transaction Process Model will continue to serve a useful pur- When knowledge of the concepts and the pose in delivering professional nursing care. The transaction process has been used in hospi- ideas have been tested in research and in practice, tals, homes, nursing homes, and community and nurses in education and practice have used the health agencies, nurses have been motivated knowledge of the concepts. The relevance of to seek additional knowledge in formal edu- evidence theory–based practice, using my theory, cational programs. Publications, including Frey & Sieloff (1995), identified from a review of the literature, will be summarized and briefly discussed. Finally, of King’s recommendations will be made for future knowl- edge development in relation to King’s Interacting Systems Framework and midrange theory, par- Theory of Goal ticularly in relation to the importance of their application within an evidence-based practice environment. Attainment Christina Leibold Sieloff, Maureen Application of Interacting Frey, & Mary Killeen Systems Framework In conducting the literature review, the authors began with the broadest category of application— application within the Interacting Systems Frame- Application of Interacting Systems work to nursing care situations. Because a con- Framework In conducting the literature review, the Concept Development Within the authors began with the broadest category Framework of application—application within the Interacting Systems Framework to nursing Theory of Goal Attainment care situations. Recommendations for Knowledge Development Related to King’s ceptual framework is, by nature, very broad and Framework and Theory abstract, it can only serve to guide, rather than prescriptively direct, nursing practice. Summary King’s Interacting Systems Framework has been used to guide nursing practice in several References ways. Fawcett, Vaillancourt, and Watson (1995) used the frame- Since the first publication of Dr. Imogene King’s work to guide nursing practice in a large tertiary work (1971), nursing’s interest in the application of care hospital. The fact that she the framework to guide nursing practice with spe- was one of the few theorists who generated both a cific patient populations. Doornbos (2002) ex- framework and a midrange theory further ex- plored family health in families with chronically panded her work. Table 16–1 delineates other appli- to publish and examine new applications of her cations related to King’s Interacting Systems work. Alligood (1995) applied the theory to within the Framework orthopedic nursing with adults. In contrast, Advocacy Bramlett, Gueldner, 1990 Benedict and Frey (1995) examined the use of the and Sowell theory within the delivery of emergency care. Autonomy Glenn* 1989 The midrange Theory of Goal Attainment Coping King 1983 (King, 1981) is also used when nurses wish to ex- Empathy Alligood, Evans, and 1995 plore a particular concept within a theoretical con- Wilt text. Temple and Fawdry (1992) examined caregiver Health King 1990 role strain while perceptual congruency between Health (social system) Sieloff 1995 nurses and clients was explored by Froman (1995). Health (systems) Winker 1995 Nurses also use the Theory of Goal Attainment Power Hawkes 1991 (King, 1981) to examine concepts related to the Quality of life King 1993 theory. This application was demonstrated by Social support Frey 1989 Kameoka (1995) as she analyzed nurse-patient in- Space Rooke 1995 teractions in Japan. Transaction Binder* 1992 Finally, the theory has been applied in nonclini- cal nursing situations. Messmer (1995) used the *Indicates thesis or dissertation theory in implementing theory-based nursing practice. In summary, Table 16–3 system (Sieloff, 1995b), health of systems (Winker, chronicles applications of King’s midrange Theory 1995), and space (Rooke, 1995b). Within the nursing profession, the nursing pro- cess has consistently been used as the basis for Theory of Goal Attainment nursing practice.

Substance Misuse 295 Table 8 Manifestations of Sedative-Hypnotic Drug Intoxication and Withdrawal Mild Sedation discount vasotec 5 mg on-line, disorientation purchase vasotec 10 mg on line, slurred speech purchase 5 mg vasotec mastercard, ataxia, nystagmus Severe Coma, hypoventilation, hypotension, hypothermia, depressed or absent corneal, gag and deep tendon reflexes Withdrawal Anxiety, insomnia, irritability, agitation, anorexia, tremor, seizures Manifestations of intoxication and withdrawal are given in Table 8. Tol- erance usually develops after continuous use, slowly for those drugs that have a long half-life but more quickly for the short-acting drugs (29). Benzodiaz- epines are well absorbed from the gastrointestinal tract after oral administra- tion; food can delay the rate but not the extent of absorption. Side effects of use include daytime drowsiness, aggravation of depres- sion, and anterograde amnesia (30) at therapeutic doses, the risk increasing at high dosages. Amnesic effects may be associated with inappropriate behaviors and other paradoxic behavioral responses, such as increased aggression, excite- ment, confusion, and restlessness (31,32). Rage reactions with violent behavior are most likely in people with a history of aggressive behavior or unstable emo- tional behavior. Anxiolytics lower tolerance to alcohol and in high doses pro- duce mental confusion similar to alcohol intoxication. How- ever, in general, they have a high toxic–therapeutic ratio, and doses 15–20 times the therapeutic dose may not cause serious side effects (33). Sudden cessation of benzodiazepines can lead to a recognized withdrawal syndrome (34) with anxiety symptoms, disordered perceptions, and major complications, such as seizures and psychosis (35). A long-acting benzodiaz- epine, such as diazepam or chlordiazepoxide, is preferable in treating symp- toms of withdrawal and preventing the major complications. Flumazenil is a specific benzodiazepine antagonist used for the rever- sal of benzodiazepine-induced sedation and coma. When overdosage is sus- pected, it can be used in patients who would otherwise need intubation and ventilation (36), but care should be taken when mixed overdoses are sus- pected (37). Complications, such as convulsions, dysrhythmias, heart block, and cardiac arrest, suggest that its use in the prehospital environment should not be encouraged (38). Barbiturates Barbiturates are used in the treatment of epilepsy and for the induction of anesthesia. They became less commonly misused after the introduction of benzodiazepine drugs but may be used by polydrug users. Mild intoxication may result in slurred speech, oversedation, ataxia, and nystagmus, although severe intoxication may present with coma, absent reflexes, hypothermia, hypotension, and respiratory depression. Physical and psychological dependence occurs, and the withdrawal syndrome is similar to that of benzodiazepine withdrawal, with a greater risk of seizures. Benzodiazepines may be used to prevent the withdrawal syndrome associated with barbiturates (35). Adhesives, aerosols, anesthetics, dry cleaning agents, fuel gases, nail varnish, and paint stripper are among the substances inhaled (39), either directly from their containers, from a plastic bag placed over the nose and mouth, from impregnated rags, or sprayed directly into the mouth. Regular users may have nasal sores, known as “glue-sniffer’s rash” (perioral dermatitis), and have the odor of solvents on their breath. Acute effects begin within minutes (40) and may last 15–45 minutes; persistent abnormalities may occur in severe chronic abusers (Table 9) (41). Animal experi- ments confirm that myocardial sensitivity may continue for hours after the initial inhalant exposure (43). Tolerance may develop, and psychological dependence after long-term use and a withdrawal syndrome similar to delirium tremens has been described (44). There is a recovery period of 10–12 hours, where there may be periods of normal perception and cognition alter- nating with degrees of intoxication, which may affect fitness for interview. Acute effects include tachycardia, hypertension, pyrexia, dilated pupils with both anisocoria (unequal size) and hippus (spasmodic rhythmical dilation and constriction), dry mouth, sweating, flushing, tremor, and hyper-reflexia. Emotional lability, euphoria and anxiety, distortion of time, visual and audi- tory illusions (although true hallucinations can occur), and synesthesia, with a mixing of the sensory input—“seeing” sounds or “hearing” smells—may all occur (46). Both enjoyable and unpleasant effects, a “bad trip” may occur in a first- time user or with repeated use (47). Five major categories of psychiatric adverse effects have been described, which include anxiety and panic attacks, self-destructive behavior, hallucinations, acute psychosis, and major depres- sive reactions (48). Phencyclidine Phencyclidine, known as “angel dust,” is usually smoked, although it can be taken orally, intravenously, or by nasal inhalation. At low doses, euphoria, relaxation, and an altered body image may occur, but at higher doses, there may be agitation, bizarre behavior, and a paranoid psychosis (50). Physical effects include nystagmus (lateral and vertical), and with severe intoxication there is adrenergic stimulation with hypertension, tachy- cardia, flushing, hyperthermia, and cholinomimetic stimulation with sweat- ing, hypersalivation, miosis, dystonia, ataxia, and myoclonus eventually resulting in coma, respiratory arrest, and circulatory collapse (51).

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