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Underlying chronic conditions (including chronic pain such as arthritis) are more common among older people discount fildena 150 mg with mastercard. Arthritis may be visually apparent effective fildena 50mg, but individual assessment may identify other needs order fildena 100 mg with amex, enabling nurses to avoid inflicting accidental pain generic 150mg fildena overnight delivery. Physiological effects With age, cardiovascular homeostasis slows and baroreceptors become less sensitive (Rebenson-Piano 1989), impairing response to sudden hypotension. Cross-linking of collagen fibres causes calcium deposit formation (Herbert 1991), reducing penetrability of arterial tunica to lipids (e. Lipid accumulation forms plaque, enabling platelet adhesion and aggregation within the arterial lumen (Todd 1997). Thrombi and emboli can cause ischaemia and major organ failure (cerebrovascular accidents, myocardial infarction, renal failure, pulmonary embolus). Myocardial collagen cross-linking limits ventricular filling, so reducing stroke volume. Most respiratory insufficiency in older people is caused by ageing of airway tissue, chemical damage (especially smoking and environmental pollutants) and muscle atrophy. Average pulmonary function is halved between 30 and 90 years of age (Hough 1996); decreased expiratory recoil reduces vital capacity and lung compliance. Pulmonary circulation also suffers atherosclerosis, increases pulmonary artery pressures. Older people are more frequently malnourished than younger people (Doyle 1990) due to factors such as poverty, poor mobility, maldentition, lack of facilities or constipation. Gastrointestinal tract atrophy makes villi shorter and broader, reducing bowel fluid absorption (Herbert 1991). The liver is a major source of body heat, and so reduced hepatic function contributes to impaired thermoregulation. Central nervous system degeneration progresses throughout life so that older patients are more likely to suffer: ■ organic brain disease (e. However, confusion may be caused by ■ absence of sensory aids (glasses, hearing aid) ■ hypoxia ■ toxic metabolites ■ alcohol (alcoholism is increasing among older people (Godard & Gask 1991)). Therefore, apparent ‘confusion’ should be holistically assessed, and care planned to meet individual needs. Reality orientation can provoke aggression (sensory imbalance); psychiatry has developed a range of alternative approaches, such as validation therapy (Feil 1993), that seeks to empower rather than control people, but most approaches rely on verbal responses, limiting their value for intubated, sedated patients. As skin ages, epidermis flattens, with loss of papillae (Herbert 1991) so that epidermal and dermal layers peel apart more easily, causing pressure sores from sheering (see Chapter 12). Capillary loss reduces oxygen, nutrients and hydration; skin becomes dryer, more brittle and prone to tearing with delayed healing. Most pressure sores occur in people over 70 years of age (Mihissin & Houghton 1995), hence the weighting for age on Waterlow and other assessment scales. Pressure area aids can reduce the incidence of pressure sores, but optimising endogenous factors (nutrition, perfusion) reduces risks. Muscular and skeletal atrophy contribute to weakness (which delays weaning from ventilation). Mortality is easily measured, but quality of life is a more valuable (if more subjective) measure of outcome. Conflicting research and practice makes healthcare for the critically ill older adults into a covert lottery. Ageism ‘Ageism’, the ‘notion that people cease to be people…by virtue of having lived a specific number of years’ (Comfort 1977:35), leads to ■ prejudice ■ stereotyping ■ negatives attitudes (Redfern 1991) and may be overt (e. Today’s elders grew up before the National Health Service existed, and so remember a very different society (and social values)—doctors (and nurses) then were presumed always to know best. Therefore, the beliefs and values of the older patients may differ significantly from those of the nurses caring for them—and different generational values may cause misunderstandings. Bereavement, social mobility and physical immobility are more likely to leave older people isolated, depriving them of the social supports (families, friends) that younger people usually have; friends and family may treat the older person as a burden. Psychological isolation can become self-fulfilling, encouraging older people to adopt child-like dependent behaviour and/or appear confused. Problems encountered by older people using hospital services can persist after leaving the department; specialised assessment forms for older people (e.

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Acknowledging ing: colleagues within the practice and discipline order 150mg fildena with amex, the interrelatedness of all living things energizes other health-care colleagues from varied disci- caring from this broader perspective into a wider plines buy generic fildena 50mg online, grant funders discount fildena 25 mg mastercard, and other collaborators generic fildena 25 mg line. Kleffel (1996) described this as “an ecocentric notion of a transdisciplinary care is an exemplar of approach grounded in the cosmos. Another defining ronment, including inanimate elements such as characteristic of community, according to Peck, is rocks and minerals, along with animate animals and willingness to risk and to tolerate a certain lack plants, is assigned an intrinsic value” (p. The practice guided by the model re- rects thinking about the interconnectedness of all flects this in fostering a creative approach to pro- elements, both animate and inanimate. Teaching, gram development, implementation, evaluation, practice, and scholarship require a caring context and research. The intention to know others as experts in their self-care while listening to their hopes and dreams for well-being creates a com- Structure of Services munion between the client and provider that and Activities guides the development of a nurturing relation- ship. Knowing the other in relationship to their The model is envisioned as three concentric circles communities, such as family, school, work, wor- around a core. Envisioning the model as a water ship, or play, honors the complexity of the context color representation, one can appreciate the vi- of persons’ lives and offers the opportunity to brancy of practice within the model, the amor- understand and participate with them. This includes participants in inquiry are focused on (a) consultation and collaboration: groups, parents/guardians, school faculty, and non- building relationships and community with mem- instructional staff, after-school groups, parent/ bers and collaborating about scholarship, policy, teacher organizations, and school advisory coun- outcomes, practice, research, educational needs of cils. The services provided within this circle might school nurses and advanced practice nurses, and include: (a) consultation and collaboration: building sustainability through ongoing and additional relationships and community, answering inquiries funding; (b) appraisal and evaluation: school nurs- on matters of health and well-being, providing in- ing and advanced practice faculty organizations service and health education, serving on school offer a milieu for discussion and appraisal of the committees, reviewing policies and procedures; (b) services provided at the centers. Organizations in appraisal and evaluation: conducting community this circle include Florida Department of Health: assessments, appraising care provided, evaluating Office of School Health, Florida Association of outcomes, and promoting programs that enhance School Nurses, Florida Association of School well-being for individuals and communities. Health, National Association of School Nurses, Na- tional Assembly of School-Based Health Centers, and the National Nursing Centers Consortium. The core service of consul- advising groups include the school district and tation and collaboration is a primary focus of prac- county public health department, the county tice, beginning with nursing and social work health-care district, Children’s Service Council, colleagues and extending to participating clients, American Lung Association, and the American Red families, policy makers, funders, and legislators. Local funders who offer support for use of This value-laden service has been essential to the the model include the Health Care District of Palm viability and sustainability of this model. It pro- Beach County, which offered initial support, and motes the stance of humility that guides the re- the Quantum Foundation, the ongoing sustaining spectful question throughout the circles: How can funder. The answer directs the cre- (a) consultation and collaboration: building rela- ation of respectful individualized care and program tionships and community with members of these development. Essential health-care services are groups, contributing to policy appraisal, develop- created within the core and extend into the first ment, and evaluation, leading and serving on teams circle. Committees on community health, and designing research projects which center administrators and staff serve meet focused on school/community health issues and or regularly to discuss school and community health school/community nursing practice. The celebrity chef cooking club: A peer in- agreement with the health-care district, many of volvement feeding program promoting cooperation and community building. Florida Journal of School Health, our clients without health insurance can be en- 9(1), 17–20. A retrospective: Looking back on Linda Rogers Physicians are consultants for medical questions and the history of school nursing. School nurse education is also pro- annual Florida Association of School Nurses Conference: vided for nurses in the local county and in sur- Past, Present and Future: Continuing the Vision. Nursing a school-aged child breadth of relationships developed at meetings, and provides an insight to the Guatemalan culture. Florida Journal through publications and presentations at local, of School Health, 9(1), 29–36. The different drum: Community making and provided for both creating and sustaining peace. Designing a nursing model of primary This model provides the environment in health care and early intervention. Paper presented at the International Association mission and philosophy of the College of of Human Caring Research Conference, the Primacy of Love and Existential Suffering, Helsinki, Finland. Community practice guided staff are encouraged to practice from these by a nursing model. Nursing Science Quarterly, 12(2), beliefs and to reach out and through the con- 125–131.

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Culture results are often negative; culture results’ yield may be improved discount fildena 25 mg otc, however fildena 100 mg lowest price, by placing 10 mL of ascitic fluid in a blood culture bottle order 25mg fildena otc. Gram-negative Enterobacteriaceae (eg purchase fildena 50 mg on-line, E coli, Klebsiella) account for 63% of all cases. For the past 2 days he has been feeling weak and over the last 6 hours he has noticed that his heart is racing. You are a passenger aboard an airplane and a 78-year-old woman is complaining of chest pain and difficulty breathing. On examination, the patient is in obvious dis- tress, but able to answer basic questions. You confirm that his airway is patent, breath sounds are equal bilaterally, and his abdomen is soft and nontender. His right leg is shorter than his left leg, slightly angu- lated, and swollen in his anterior thigh area. You are called to the bedside of a hypotensive patient with altered mental status. You feel that the patient is unstable and elect to perform emergency cardioversion. Paramedics bring in a 54-year-old man who was found down in his apartment by his wife. Records indicate that he has a past medical history of hyper- tension, diabetes, dementia, and benign prostatic hypertrophy. His lungs are clear to auscultation, with scant crack- les at the bases, and his abdomen is soft, nontender, and nondistended. The nurse places the patient on a cardiac monitor and begins to get his vital signs. While the nurse is obtaining the vital signs, he notices the patient suddenly becomes unresponsive. A 34-year-old woman with no known medical problems is having a sushi dinner with her husband. Halfway through dinner, she begins scratching her arms and her husband notices that her face is flushed. The itching intensifies and she begins to feel chest pain, shortness of breath, and dizziness. As you perform laryngoscopy to intubate the patient, you easily visualize the vocal cords and subsequently pass the orotracheal tube through the vocal cords. You place the colorimetric end-tidal carbon diox- ide device over the tube and get appropriate color change. There are equal, bilateral breath sounds on auscultation and you observe chest wall motion with ventilation. He has a past medical history of hypertension and diabetes and both are well controlled on hydrochlorothiazide, benazepril, atenolol, and metformin. He has grossly normal peripheral sensation, but no motor strength in all four extremities. He has been unable to get out of bed for the past day because of dizziness when changing position. A few minutes later, the nurse alerts you that the patient has become unconscious. A 48-year-old man with a medical history of cirrhosis caused by hepatitis C has been vomiting bright red blood for 1 day. You are concerned about meningo- coccemia and immediately start ceftriaxone and vancomycin. His medications include albuterol, ipratropium, prednisone, hydrochlorothiazide, and atenolol. A 64-year-old woman with a history of depression and hypertension was found down by her husband and brought in by the paramedics. Her husband says that she has recently been depressed and expressed thoughts of suicide.

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