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By Q. Bandaro. East Central University, Ada Oklahoma. 2018.

Residents are strongly encouraged to take meals Resolved Care Plans Care Conference Records in groups cheap 100 mg viagra mastercard, to see movies or watch television together buy discount viagra 75 mg line, to Vital Signs attend musical events cheap viagra 100 mg amex, and to vote cheap 25mg viagra. These activities are Lab and Special Reports either brought to them in the facility or arranged in Medication Administration Record (MAR) "field-trip" fashion. Again, physicians may be slow to Treatments comprehend this fundamental atmosphere of patient Dietary Occupational Therapy autonomy. Physicians are used to meting out admonitions Physical Therapy and directives to patients in the office, clinic, or hospital. Speech Therapy Patients are referred to as "residents" in the SNF—this is Quality of Life/Activities their home, where they are boss. The admonitions and Social Work directives are supposed to come from them to the staff Miscellaneous and physicians, not the other way around. Acute psychotic episodes imposed or psychoactive drug administered for purposes of 6. Brief reactive psychosis discipline or convenience and not required to treat the resident’s 7. Tourette’s disorder mechanical device, material, or equipment attached or adjacent 10. Huntington’s disease to the resident’s body that the individual cannot remove easily 11. Organic mental syndromes (including dementia) with which restricts freedom of movement or access to one’s body associated psychotic and/or agitated features as (includes leg and arm restraints, hand mitts, soft ties or vest, defined by wheelchair safety bars, and gerichairs). There must be a trial of less restrictive measures unless the scratching) documented by the facility which causes physical restraint is necessary to provide lifesaving treatment. The resident or his/her legal representative must consent to the —Present a danger to themselves use of restraints. Residents who are restrained should be released, exercised, —Actually interfere with staff’s ability to provide care toileted, and checked for skin redness every 2 h. Each resident’s drug regimen must be free from unnecessary drugs nausea, vomiting, or pruritus (1) "Unnecessary drugs" are drugs that are given in excessive (b) Antipsychotics should not be used if one or more of the fol- doses, for excessive periods of time, without adequate moni- lowing is/are the only indication toring, or in the absence of a diagnosis or reason for the drug. Impaired memory (2) In deciding whether an unnecessary drug is being used, sur- 7. Uncooperativeness (1) Residents who have not used antipsychotic drugs are not given 15. Any indication for which the order is on an "as needed" these drugs unless antipsychotic drug therapy is necessary to basis treat a specific condition. Summary of new federal regulations relevant to primary physicians and medical directors in nursing homes: 1987 Omnibus Budget Reconciliation Act (OBRA). Code Status this is a "patient order," not necessarily a physician order, in the nursing home. If the physician When physicians enter the nursing home, it is well to is called upon to sign the form as well, it is often merely an remember these two fundamental principles: one, the acknowledgment, almost an afterthought. Many nursing nursing home is run by nurses and patients, and, two, homes simply dispense with the physician signature. The patients’ rights and autonomy rule the day—after all, the MD signature merely confuses the issue as they are not the nursing home is their home. On the other hand, if a code status discomfort with nursing home practice might be traced to decision is reached that the physician feels is not appropri- misunderstanding, and not embracing, these two princi- ate, the onus is on the doctor to work with the family and ples. A sentinel example of this is the typical decision staff to establish goals appropriate to severity of illness making and ordering regarding cardiopulmonary resusci- and prognosis—an "incorrect" code status is often a tation (CPR),or its avoidance [do not resuscitate (DNR)]; good stimulus for such a heart-to-heart discussion. The Geriatrician in the Nursing Home 117 physician can and should discuss code status issues with 6 attention to patient wishes and directives). It is not patients; in the nursing home this is primarily to inform, unusual for patients to request "DNH" (do not hospital- which may or may not influence their decisions. Physician Visits Physician participation in the care of nursing home Patient Population Dynamics in the patients is also regulated. By federal law (and as Modern Nursing Home amended in some states), minimum visitation by the physician to nursing home patients includes the initial Most patients admitted to nursing homes in this day and order and approval for admission in the form of an admit- age are rehabilitated over a period of a month or two and ting history, physical, and orders. After accounted for by long-stayers, patients with slow trajec- admission, monthly visits (every 30 ± 10 days) should tories of improvement or decline, with chronic illnesses ensue for at least one quarter, then every other month such as Alzheimer’s disease or other debilitating neuro- thereafter.

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She found that both unmitigated agency and unmitigated communion are associated with negative health outcomes order viagra 100 mg mastercard. Medical family therapy emphasizes the development of a collaborative (rather than hierarchical) relationship between the health professional order 25mg viagra fast delivery, the patient cheap 75mg viagra, and the spouse or partner; this is a necessary corrective to the well- described power problems that can occur in the doctor-patient relationship (McDaniel & Hepworth purchase 25mg viagra with visa, 2004; McDaniel et al. This collaborative stance involves respecting the patient’s and family’s agendas, supporting their goals, and providing care from a consultative rather than authoritar- ian position. Techniques for helping couples and families in medical family therapy include the following: (1) recognize the biological dimension along with the psychological, (2) solicit the illness story, (3) respect defenses, (4) remove blame and accept unacceptable feelings, (5) attend to developmental issues, (6) increase sense of agency, (7) facilitate communication, and (8) remain available. Historically, various approaches to family therapy have looked askance on biological explana- tions of human functioning, in part out of an understandable concern with the reductionism of traditional biomedical approaches. In working with couples facing illness, however, it is critical to recognize the importance of biology and its profound impact on the life of the couple. It is often helpful, when possible, to sit with the couple and their physician or other member of their health care team to demystify the illness by discussing their ques- tions, concerns, and reactions to it and to the treatment recommendations. In the context of an ambiguous diagnosis or course of illness, it is im- portant to be open to many possible explanations for the patient’s sympto- matology (Ruddy & McDaniel, 2002). Illness is virtually always both bio- logical and psychological, or at least involves aspects of each. Tolerance for ambiguity in the therapist helps avoid the temptation to attribute the 258 SPECIAL ISSUES FACED BY COUPLES patient’s symptoms definitively to either psychological or biological causes. On the other hand, a clinician’s overemphasis on biological explanations risks en- couraging the patient to avoid looking at the relationship between emotions and symptom expression. It certainly happens that an illness diagnosed as psychological at one point is later found to have a bona fide biomedical cause as the illness progresses or a new diagnostic approach is taken. It can sometimes be helpful to focus on the fact that stress has been shown to ex- acerbate virtually all illnesses, whether the etiology be psychological or bio- logical, and that working to reduce stress through enhancing coping strategies is likely to be beneficial, regardless of ultimate cause. The second technique, soliciting the illness story, involves asking about the patient and couples’ experience with the illness from the time of diagnosis to the present, including the associated feelings. Understanding the emo- tional and family context of the illness is facilitated through inquiry about family illness history, illness meanings, and transgenerational health beliefs and coping strategies. A respectful collaborative relationship greatly facili- tates the eliciting of the illness story from the patient and spouse or partner, and lays the foundation for developing a successful partnership for care. Views of illness and of the relationship with health care providers varies by cultural group, and often by gender. These views can present special challenges to the health professional and the psychotherapist. Because of the power differential, women may need to develop a trusting relationship with their health care provider before being able to share their illness story. For men, sharing their experience of illness may conflict with American male socialization that discourages expression or acknowledgment of vul- nerability; patient, supportive questioning by the therapist may therefore be required. The development of an effective therapeutic relationship in medical fam- ily therapy requires respecting the patient and partner’s defenses, diminishing blame and guilt, and accepting unacceptable feelings in reaction to illness. An over- functioning spouse who falls ill will be prone to feel guilt and self-blame about not being able to maintain previous levels of functioning. The stress and anxiety that accompanies illness can generate irritability and blame to- ward the sick (or toward the healthy) spouse or partner. Gender roles can compound the difficulty of adjusting to the demands of illness—for exam- ple, unacceptable feelings may arise related to ways in which men or women respond to illness that run counter to their gender script. A man who is weepy or a woman who is angry in response to a new diagnosis may feel the additional burden of criticism from others. Medical family therapy works to counteract the dehumanizing experience of these gender scripts (McDaniel & Cole-Kelly, 2003). Managing Emotional Reactivity in Couples Facing Illness 259 It is important to understand developmental issues at the individual, couple, and family levels as they interact with the demands of the illness or disabil- ity (Rolland, 1994). For example, breast cancer in a woman of child-bearing age will have different psychosocial implications than at other stages of de- velopment as she struggles with the need for treatment (e. The development of a serious illness in a member of a couple entering retirement may provide unique challenges around adjustment to a life filled with patienthood and caregiving in con- trast to the active retirement they had planned for themselves. Increasing agency is accomplished through providing psychoeducation and information for men and women, encouraging the patient, couple, and family to maintain individual, couple, and family identities, developing flexible roles in caring for the illness, and drawing out individual and family strengths and resources. Connection (or communion) between the patient and the family, and the patient and the health care team, is strengthened through ongoing at- tention to clear communication.

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For example generic viagra 100 mg otc, good A high quality decision aid should evidence exists that amniocentesis performed on pregnant + Be evidence-based generic 75mg viagra mastercard, using evidence-based statements of women who are > 35 years of age is effective in detecting benefits and risks from credible sources; refer to the quality abnormalities purchase viagra 25 mg on-line, but not all women choose the procedure because and consistency of empirical studies; and use systematic their values about the medical options and potential outcomes overviews that extend shelf life and enhance updating differ viagra 50 mg fast delivery. Benign prostatic hypertrophy is another example because + Be balanced in presenting all options (including doing it has several management options (watchful waiting, drugs, or nothing), the benefits and risks of all options, and (when surgery) and potential outcomes (amount of symptom relief v available) examples of others’ decisions and opinions drug side effects or surgical risks of incontinence and + Have credible developers with expertise as evidence inter- impotence) that each patient may value differently. The table However, the impact of decision aids on satisfaction with lists the decision aids that have been developed, evaluated, and decision making is more uncertain. We also need to know which decision aids work best programs/clinical-epidemiology/ohdec. Although decision aids have been quite beneficial relative on counselling focuses on personal deliberation rather than to usual care, the differences between simpler and more detailed providing factual information. This delivery The definition of a patient decision aid is open to broad strategy may become more feasible in other countries as interpretation, and materials of variable quality have been pro- tele-health services expand (eg, NHS Direct in the UK and duced. Decisionaidsforpatientsfacinghealth ing best practices for deploying those decision aids that have treatment or screening decisions: a Cochrane systematic review. A manual for assessing health practices and designing practice policies: University of Ottawa School of Nursing and Department of Epidemiology the explicit approach. Decision aids for patients consid- Ottawa,Ontario,Canada ering health care options:evidence of efficacy and policy implications. Features of the site include: x Full text, downloadable in PDF format x Links to primary papers and references—full text links to > 200 journals even if you don’t subscribe to them x Browse by keyword or topic x Direct access to Medline x Email table of contents alerts We invite you to take a look at the web site and email us via the feedback facility with any comments. Brian Haynes Paul Glasziou Journals reviewed for this issue* Acta Obstet Gynecol Scand Arch Neurol Diabetes Care J Neurol Neurosurg Psychiatry Age Ageing Arch Pediatr Adolesc Med Fertil Steril J Pediatr Am J Cardiol Arch Surg Gastroenterology J Vasc Surg AmJMed Arthritis Rheum Gut Lancet Am J Obstet Gynecol BMJ Heart Med Care Am J Psychiatry Br J Gen Pract Hypertension Med J Aust Am J Public Health Br J Obstet Gynaecol JAMA NEnglJMed Am J Respir Crit Care Med Br J Psychiatry J Am Board Fam Pract Neurology Am J Surg Br J Surg J Am Coll Cardiol Obstet Gynecol Ann Emerg Med CMAJ JAmCollSurg Pain Ann Intern Med Chest J Am Geriatr Soc Pediatrics Ann Med Circulation J Clin Epidemiol Rheumatology Ann Surg Clin Invest Med J Fam Pract Spine Arch Dis Child Clin Pediatr J Gen Intern Med Stroke Arch Fam Med Cochrane Library J Infect Dis Surgery Arch Gen Psychiatry Crit Care Med J Intern Med Thorax Arch Intern Med *Approximately 60 additional journals are reviewed. The aim should be concentrations of phenytoin peak at 10 minutes and to halt this activity urgently. Local reactions to phenytoin occur airway reflex effects, and have no harmful effects. For often and thrombophlebitis necessitates frequent status epilepticus fosphenytoin is safe and effective in changes of cannulas and makes central administration the emergency initiation and maintenance of anticon- the preferred route. United States and can be administered intravenously M T E Heafield consultant neurologist or intramuscularly. Studies have found it to be as effec- Queen Elizabeth Hospital,Birmingham B15 2TH tive as phenytoin in treating status epilepticus, with several advantages over its parent drug. In one series of MTEH has received a fee for speaking on status epilepticus and 81 patients with generalised convulsive status epilepti- fosphenytoin at a study day organised by Parke Davis. Current Intramuscular administration of fosphenytoin has concepts in neurology: management of status epilepticus. N Engl J Med benefits: rapid and complete absorption, no require- 1982;306:1337-40. Clinical experience with fosphenytoin in adults: ment for cardiac monitoring, and a low incidence of pharmacokinetics, safety, and efficacy. Refractory status is characterised by seizure activity Safety and pharmacokinetics of fosphenytoin (Cerebyx) compared with for about an hour in which the patient has not Dilantin following rapid intravenous administration. Intravenous administration of fosphenytoin: mended to abolish electroencephalographic and options for the management of seizures. Intramuscular fosphenytoin (Cerebyx) in patients requiring a the newer agent propofol and older thiopentone, loading dose of phenytoin. Intramuscular use of fosphenytoin: whose disadvantages include a tendency to accumulate an overview. Practitioners of evidence based care Not all clinicians need to appraise evidence from scratch but all need some skills igh quality health care implies practice that is and values. H tively appealing way to achieve such evidence After a decade of unsystematic observation of an based practice is to train clinicians who can independ- internal medicine residency programme committed to ently find, appraise, and apply the best evidence (whom systematic training of evidence based practitioners,1 we we call evidence based practitioners). Indeed, we have concluded—consistent with predictions2—that not ourselves have advocated this approach.

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An expression for the vertical ground force acting on each foot can be obtained by substituting Eqn discount viagra 100 mg otc. As for the horizontal ground forces acting on each foot buy 50mg viagra with visa, we substitute Qh 5 0 in Eqn 75mg viagra overnight delivery. With- out this approximation buy generic viagra 75 mg on-line, it would not be possible to assign unique values for these ground forces by only considering the laws of motion for the whole body. We have not taken into account the fact that the feet remain more or less vertical during push-up rather than aligned with the rest of the body. Second, it is relatively easy to determine the time history of u using equipment available in most engineering departments. One could hook up a videocamera to a computer and digitize the videoimage of the push-up events. Appropriate software can then be used to assess the val- ues of u, du/dt, and d2u/dt2 as a function of time. In this way, it is possi- ble to study the effect the rate of motion has on the ground forces. Note that the ground reaction forces can also be measured directly, but one would need two force plates to quantify these contact forces. In many instances, particularly when we want to in- vestigate locomotion (walking, running, jumping) or movement in air, it is more convenient to consider moment of momentum about the center of mass. Using parallegram law of vector addition: ri/o 5 rc/o 1 ri/c Substituting this expression into the equation for moment of momentum about point O, we find: Ho 5 rc/o 3 L 1Sri/c 3 mivi (3. Because the time derivative of the moment of momentum about point O is equal to the resultant moment acting on the system with respect to point O, we find: rc/o 3SFi 1 dHc/dt 5Sri/o 3 Fi 5S(rc/o 1 ri/c) 3 Fi dHc/dt 5Sri/c 3 Fi (3. Particles in Motion According to this equation, the time rate of change of moment of mo- mentum about the center of mass is equal to the sum of the moments of external forces and force couples with respect to the center of mass. Determine how rigor- ously one has to swing the arms to avoid twisting during walking. Thus, the total moment of momentum with respect to the center of mass can be written as Hc 5 2d L m (du /dt) cos u e 2 2d L m (du /dt) cos u e a a a a a 2 l l l l l 2 in which the subscripts a and l refer to the upper and lower limbs, re- spectively. First, the left arm must rotate in the same direction as the right leg and vice versa to cancel the contributions of arm and leg swing to the moment of momentum of the human body. Second, because the lower limbs are longer and heavier than the upper limbs, the arms must rotate faster to cancel out the twisting effect of the legs. As the arms and the legs have the same period of swing, the way to achieve zero moment of momentum from swing is to increase the amplitude of swing of the arms while also increasing their rate of rotation. Linear momentum of a system of particles is defined as the sum of the products of the mass of each particle with its velocity: L 5S(mi vi) in which mi is the mass of particle i and vi is its velocity. Writing Newton’s second and third law for each particle in a system of particles and sum- ming over all particles in the system, one can show that dL/dt 5SFi where SFi denotes the sum of all external forces acting on the system of particles. Gravitational force and the forces that arise as the result of contact of particles in the system with the particles outside the system are external forces. Newton’s third law re- quires that forces that act between particles in the system under study do not contribute to the change of linear momentum. The center of mass of a system of particles is defined by the relation: (Smi) rc 5S(mi ri) in which rc denotes the position of center of mass with respect to a Carte- sian reference frame and ri is the position vector of particle i. The center of mass is not necessarily occupied by any particle in the system of par- ticles. Using this definition in the equation for the conservation of linear momentum, one obtains an equation governing the position of the cen- ter of mass as a function of time: SFi 5 (Smi) ac in which ac is the acceleration of the center of mass. The term moment of momentum about a point fixed on earth is defined by the following equation: Ho 5Sri/o 3 mivi in which ri/o denotes the position vector from the stationary point O to the particle i. The conservation of moment of momentum dictates that dHo/dt 5Sri/o 3 Fi Again, in this equation, Fi represents the external force i acting on the ith particle of the system. Conservation of moment of momentum about the center of mass is governed by an equation of the same form: dHc/dt 5Sri/c 3 Fi where Hc 5Sri/c 3 mivi and ri/c is the position vector from the center of mass to the particle i.

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