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By M. Stan. Chaminade University of Honolulu, Hawaii.

Regardless of which type of modeling the children had seen 250 mg flutamide otc treatment deep vein thrombosis, and regardless of the sex of the model or the child cheap flutamide 250mg without a prescription medications 563, the children who had seen the model behaved aggressively—just as the model had done trusted flutamide 250mg treatment action campaign. Bandura and his colleagues had demonstrated that these children had learned new behaviors trusted 250 mg flutamide symptoms your dog has worms, simply by observing and imitating others. Observational learning is useful for animals and for people because it allows us to learn without having to actually engage in what might be a risky behavior. Monkeys that see other monkeys respond with fear to the sight of a snake learn to fear the snake themselves, even if they have [4] been raised in a laboratory and have never actually seen a snake (Cook & Mineka, 1990). As Bandura put it, the prospects for [human] survival would be slim indeed if one could learn only by suffering the consequences of trial and error. For this reason, one does not teach children to swim, adolescents to drive automobiles, and novice medical students to perform surgery by having them discover the appropriate behavior through the consequences of their successes and failures. The more costly and hazardous the possible mistakes, the heavier is the reliance on [5] observational learning from competent learners. These children are not only the victims of aggression, but they also see it happening to their parents and siblings. Because children learn how to be parents in large part by modeling the actions of their own parents, it is no surprise that there is a strong correlation between family violence in childhood and violence as an adult. Children who witness their parents being violent or who are themselves abused are more likely as adults to inflict abuse on intimate partners or their children, and to be victims of intimate violence (Heyman & Slep, [6] 2002). In turn, their children are more likely to interact violently with each other and to [7] aggress against their parents (Patterson, Dishion, & Bank, 1984). Research Focus: The Effects of Violent Video Games on Aggression The average American child watches more than 4 hours of television every day, and 2 out of 3 of the programs they watch contain aggression. It has been estimated that by the age of 12, the average American child has seen more than 8,000 murders and 100,000 acts of violence. At the same time, children are also exposed to violence in movies, video games, and virtual reality games, as well as in music videos that include violent lyrics and imagery (The Henry J. It might not surprise you to hear that these exposures to violence have an effect on aggressive behavior. The evidence is impressive and clear: The more media violence people, including children, view, the more aggressive they are likely [9] to be (Anderson et al. The relation between viewing television violence and aggressive behavior is about as strong as the relation between smoking and cancer or between studying and academic grades. People who watch more violence become more aggressive than those who watch less violence. It is clear that watching television violence can increase aggression, but what about violent video games? Youths spend countless hours playing these games, many of which involve engaging in extremely violent behaviors. The games often require the player to take the role of a violent person, to identify with the character, to select victims, and of course to kill the victims. These behaviors are reinforced by winning points and moving on to higher levels, and are repeated over and over. A recent meta-analysis by Anderson and [10] Bushman (2001) reviewed 35 research studies that had tested the effects of playing violent video games on Attributed to Charles Stangor Saylor. The studies included both experimental and correlational studies, with both male and female participants in both laboratory and field settings. They found that exposure to violent video games is significantly linked to increases in aggressive thoughts, aggressive feelings, psychological arousal (including blood pressure and heart rate), as well as aggressive behavior. Furthermore, playing more video games was found to relate to less altruistic behavior. Participants were randomly assigned to play either a violent or a nonviolent video game for 20 minutes. Each participant played one of four violent video games (Carmageddon, Duke Nukem, Mortal Kombat, or Future Cop) or one of four nonviolent video games (Glider Pro, 3D Pinball, Austin Powers, or Tetra Madness). Participants then read a story, for instance this one about Todd, and were asked to list 20 thoughts, feelings, and actions about how they would respond if they were Todd: Todd was on his way home from work one evening when he had to brake quickly for a yellow light. The person in the car behind him must have thought Todd was going to run the light because he crashed into the back of Todd’s car, causing a lot of damage to both vehicles. They said things like ―Call the guy an idiot,‖ ―Kick the other driver‘s car,‖ ―This guy‘s dead meat! Violent video games and hostile expectations: A test of the general aggression model. However, although modeling can increase violence, it can also have positive effects. Research has found that, just as children learn to be aggressive through observational learning, they can also learn to be altruistic in the same way [12] (Seymour, Yoshida, & Dolan, 2009). Imagine that you had a 12-year-old brother who spent many hours a day playing violent video games. Basing your answer on the material covered in this chapter, do you think that your parents should limit his exposure to the games? How might we incorporate principles of observational learning to encourage acts of kindness and selflessness in our society? Selective associations in the observational conditioning of fear in rhesus monkeys. The relationship between indirect and physical aggression on television and in real life. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: A meta-analytic review of the scientific literature. Violent video games and hostile expectations: A test of the general aggression model. Review the ways that learning theories can be applied to understanding and modifying everyday behavior. Describe the situations under which reinforcement may make people lesslikely to enjoy engaging in a behavior. Explain how principles of reinforcement are used to understand social dilemmas such as the prisoner’s dilemma and why people are likely to make competitive choices in them. The principles of learning are some of the most general and most powerful in all of psychology. It would be fair to say that these principles account for more behavior using fewer principles than any other set of psychological theories. For example, operant conditioning has been used to motivate employees, to improve athletic performance, to increase the functioning of those suffering from developmental disabilities, and to help parents successfully toilet train their children (Simek & O‘Brien, 1981; [1] Pedalino & Gamboa, 1974; Azrin & Foxx, 1974; McGlynn, 1990). In this section we will consider how learning theories are used in advertising, in education, and in understanding competitive relationships between individuals and groups. Using Classical Conditioning in Advertising Classical conditioning has long been, and continues to be, an effective tool in marketing and [2] advertising (Hawkins, Best, & Coney, 1998). The general idea is to create an advertisement that has positive features such that the ad creates enjoyment in the person exposed to it. Because the product being advertised is mentioned in the ad, it becomes Attributed to Charles Stangor Saylor. In the end, if everything has gone well, seeing the product online or in the store will then create a positive response in the buyer, leading him or her to be more likely to purchase the product. Video Clip: Television Ads Can you determine how classical conditioning is being used in these commercials? For instance, if people enjoy watching a college basketball team playing basketball, and if that team is sponsored by a product, such as Pepsi, then people may end up experiencing positive feelings when they view a can of Pepsi.

Withdrawal can lead temically trusted 250 mg flutamide 4 medications walgreens, but is of great medical importance because of its to an abstinence syndrome consisting of craving discount flutamide 250 mg with amex symptoms type 1 diabetes, irritability and pathological and psychological effects when used as a bever- sometimes physical features (e best 250 mg flutamide symptoms ebola. Alcohol is the most important drug of dependence discount flutamide 250mg free shipping treatment plan template, and Substitution of nicotine via skin patches or nicotine gum as in Western Europe and North America the incidence of alco- part of a smoking cessation programme significantly increases holism is about 5% among the adult population. The antidepressant bupropion appears to reduce the desire to smoke and is licensed as an adjunct to motivational Pharmacokinetics support in smoking cessation. It is contraindicated in patients Ethyl alcohol is absorbed from the buccal, oesophageal, gastric with a history of seizures or of eating disorders, or who are and intestinal mucosae – approximately 80% is absorbed from experiencing acute alcohol or benzodiazepine withdrawal. Alcohol delays gastric emptying and in Varenicline, a selective nicotinic receptor partial agonist, is high doses delays its own absorption. It is started 1–2 weeks tration, alcohol can usually be detected in the blood within five before stopping smoking. Peak concentrations occur between 30 minutes and Side effects include gastro-intestinal disturbances, headache, two hours. Hepatic This group of compounds includes caffeine (present in tea oxidation to acetaldehyde is catalysed by three parallel and colas, as well as coffee), theobromine (present in choco- processes. The major effects of these com- Alcohol elimination follows Michaelis–Menten kinetics, pounds are mediated by inhibition of phosphodiesterase, with saturation occurring in the concentration range encoun- resulting in a raised intracellular cyclic adenosine monophos- tered during social drinking. Its use does not lead to Nervous system: Alcohol decreases concentration, judgement, improved intellectual performance except perhaps when discrimination, and reasoning and increases self-confidence. Progressively increasing plasma concentrations are associated Circulatory effects include direct myocardial stimulation with sensations of relaxation followed by mild euphoria, producing tachycardia, increased cardiac output, ectopic beats incoordination, ataxia and loss of consciousness. Caffeine use should be curtailed in patients concentrations, the gag reflex is impaired, vomiting may occur who suffer paroxysmal dysrhythmias. Its effect on blood pres- and death may result from aspiration of gastric contents. Cerebral vasoconstriction provides some importance of alcohol as a factor in road traffic accidents is rationale for use of caffeine in migraine. The central depressant actions of muscle relaxes and respiration is stimulated centrally. Mild alcohol greatly enhance the effects of other central depressant diuresis occurs due to an increased glomerular filtration rate drugs. In patients with organic brain damage, alcohol may subsequent to dilatation of the afferent arterioles. Chronic neurological accompaniments of persistent alcohol abuse include various forms of central Cytoplasmic and peripheral neurodegeneration, most commonly involving Catalase alcohol Microsomal the vermis of the cerebellum, and a peripheral neuropathy. Any evidence of Wernicke’s encephalopathy should be immediately treated with intravenous thiamine followed by oral thiamine for several Acetate months. Hyperuricaemia occurs (particularly, it is said, in beer drinkers) and can cause acute gout. Neutrophil dysfunction is common even when the neutrophil count is 20 normal, predisposing to bacterial infections (e. There are characteristic facial features which include microcephaly, micrognathia and a short upturned 0 20 40 60 80 100 120 140 160 180 nose. This so-called fetal alcohol syndrome is unlike that Blood alcohol concentration (mg/100 mL) reported in severely undernourished women. The patient should be nursed in a quiet environment with careful attention to fluid and electrolyte Acute effects of alcohol balance. Benzodiazepines (intravenous if necessary, Chapters • Central effects include disinhibition, impaired 18 and 22) are usually effective in terminating prolonged with- judgement, inco-ordination, trauma (falls, road traffic drawal seizures – if they are ineffective the diagnosis should accidents), violence and crime. Psychiatric assessment and social support • Convulsions, enhancement of sedative drugs. Delirium tremens occurs in less • Dependence than 10% of alcoholic patients withdrawing from • Behavioural changes alcohol. Psychological and social management: Some form of psychological and social management is important to help the patient to remain abstinent. Whatever approach is used, Medical uses of alcohol the focus has to be on abstinence from alcohol. Systemic alcohol is minority of patients may be able to take up controlled used in poisoning by methanol or ethylene glycol, since it drinking subsequently, but it is impossible to identify this competes with these for oxidation by alcohol dehydrogenase, group prospectively, and this should not be a goal of slowing the production of toxic metabolites (e. Management of alcohol withdrawal Alcohol-sensitizing drugs: These produce an unpleasant Awithdrawal syndrome develops when alcohol consumption reaction when taken with alcohol. The only drug of this type is stopped or severely reduced after prolonged heavy alcohol used to treat alcoholics is disulfiram, which inhibits aldehyde intake. Several features of acute withdrawal are due to auto- dehydrogenase, leading to acetaldehyde accumulation if nomic overactivity, including hypertension, sweating, tachy- alcohol is taken, causing flushing, sweating, nausea, cardia, tremor, anxiety, agitation, mydriasis, anorexia and headache, tachycardia and hypotension. These are most severe 12–48 hours after stopping may occur if large amounts of alcohol are consumed. Some small amounts of alcohol included in many medicines may be patients have seizures (‘rum fits’ generally 12–48 hours post sufficient to produce a reaction and it is advisable for the abstinence). A third set of symptoms consists of alcohol with- patient to carry a card warning of the danger of alcohol drawal delirium or ‘delirium tremens’ (acute disorientation, administration. Disulfiram also inhibits phenytoin severe autonomic hyperactivity, and hallucinations – which metabolism and can lead to phenytoin intoxication. Delirium tremens often follows after with- Unfortunately, there is only weak evidence that disulfiram drawal seizures and is a medical emergency. Its use should death may occur as a result of respiratory or cardiovascular be limited to highly selected individuals in specialist clinics. Management includes thiamine and other vitamin replacement, and a long-acting oral benzodiazepines (e. Acamprosate: The structure of acamprosate resembles that of chlordiazepoxide or diazepam), given by mouth if possible. It appears to reduce the effects of The initial dose requirement is determined empirically and is excitatory amino acids and, combined with counselling, it followed by a regimen of step-wise dose reduction over the may help to maintain abstinence after alcohol withdrawal. Increased metabolism of warfarin and usually of doubtful benefit but with side effects, include phenytoin have been reported in alcoholics. Alcohol enhances human chorionic gonadotrophin, growth hormone, caffeine, the gastric irritation caused by aspirin, indometacin and amphetamines, β-blockers and erythropoietin. They are Enhanced hypoglycaemia may occur following coadministra- claimed to enhance sexual pleasure and dilate the anus. Central effects are simi- euphoria, sedation, amnesia (implicated as ‘date rape’ drug), lar to alcohol. During withdrawal, convulsions are more often aggression, vomiting, coma, respiratory depression and seizure. Chloral hydrate and clomethiazole have similar potential for depend- Case history ence, and their use is difficult to justify. Laboratory tests reveal a raised mean corpuscular volume For more information on benzodiazepines, see Chapter 18. Solvents such as glues or paints are sniffed, Answer 1 often with the aid of a plastic bag to increase the concentration of Wernicke’s encephalopathy. Disinhibition can lead to excessively gregarious, aggressive or emotional behaviour. Cardiac Case history dysrhythmia can occur (as with hydrocarbon anaesthetics, A 20-year-old man is brought by the police to the Accident Chapter 24). Most deaths are associated with asphyxia as a result and Emergency Department unconscious. Excessive believe that he ingested condoms full of diamorphine prior to his arrest following a drugs raid. He had been in police chronic use is rare, but may lead to major organ failure, as custody for approximately one hour. There are no specific drug centrally cyanosed, breathing irregularly, with pinpoint therapies for solvent abusers and psychological and/or social pupils and no response to painful stimuli.

Then the researchers showed these videos purchase flutamide 250mg overnight delivery treatment carpal tunnel, without any sound cheap 250mg flutamide with visa medicine 773, to raters who did not know which medal which athlete had won generic flutamide 250 mg free shipping medications not covered by medicare. In a follow-up study purchase flutamide 250 mg overnight delivery treatment 8 cm ovarian cyst, raters watched interviews with many of these same athletes as they talked about their performance. The raters indicated what we would expect on the basis of counterfactual thinking—the silver medalists talked about their disappointments in having finished second rather than first, whereas the bronze medalists focused on how happy they were to have finished third rather than fourth. I really wanted to make it home when I got near the end of my journey; I would have been extremely disappointed if the car broke down only a few miles from my home. Perhaps you have noticed that once you get close to finishing something, you feel like you really need to get it done. Jurors who were asked to award monetary damages to others who had been in an accident offered them substantially more in compensation if they barely avoided injury than they offered if the accident seemed inevitable (Miller, Turnbull, & McFarland, [29] 1988). Psychology in Everyday Life: Cognitive Biases in the Real World Perhaps you are thinking that the kinds of errors that we have been talking about don‘t seem that important. After all, who really cares if we think there are more words that begin with the letter ―R‖ than there actually are, or if bronze medal winners are happier than the silver medalists? But it turns out that what seem to be relatively small cognitive biases on the surface can have profound consequences for people. Why would so many people continue to purchase lottery tickets, buy risky investments in the stock market, or gamble their money in casinos when the likelihood of them ever winning is so low? One possibility is that they are victims of salience; they focus their attention on the salient likelihood of a big win, forgetting that the base rate of the event occurring is very low. The belief in astrology, which all scientific evidence suggests is not accurate, is probably driven in part by the salience of the occasions when the predictions are correct. People may also take more care to prepare for unlikely events than for more likely ones, because the unlikely ones are more salient. For instance, people may think that they are more likely to die from a terrorist attack or a homicide than they are from diabetes, stroke, or tuberculosis. And people are frequently more afraid of flying than driving, although the likelihood of dying in a car crash is hundreds of times greater than dying in a plane crash (more than 50,000 people are killed on U. Because people don‘t accurately calibrate their behaviors to match the true potential risks (e. Salience and accessibility also color how we perceive our social worlds, which may have a big influence on our behavior. For instance, people who watch a lot of violent television shows also view the world as more dangerous [31] (Doob & Macdonald, 1979), probably because violence becomes more cognitively accessible for them. We also [32] unfairly overestimate our contribution to joint projects (Ross & Sicoly, 1979), perhaps in part because our own contributions are highly accessible, whereas the contributions of others are much less so. Even people who should know better, and who need to know better, are subject to cognitive biases. Economists, stock traders, managers, lawyers, and even doctors make the same kinds of mistakes in their professional activities that [33] people make in their everyday lives (Gilovich, Griffin, & Kahneman, 2002). Just like us, these people are victims of overconfidence, heuristics, and other biases. Furthermore, every year thousands of individuals, such as Ronald Cotton, are charged with and often convicted of crimes based largely on eyewitness evidence. When eyewitnesses testify in courtrooms regarding their memories of a crime, they often are completely sure that they are identifying the right person. But the most common cause of [34] innocent people being falsely convicted is erroneous eyewitness testimony (Wells, Wright, & Bradfield, 1999). Although cognitive biases are common, they are not impossible to control, and psychologists and other scientists are working to help people make better decisions. One possibility is to provide people with better feedback about their Attributed to Charles Stangor Saylor. Weather forecasters, for instance, learn to be quite accurate in their judgments because they have clear feedback about the accuracy of their predictions. Other research has found that accessibility biases can be reduced by leading people to consider multiple alternatives rather than focus only on the most obvious ones, and particularly by leading people to think about opposite possible outcomes than the ones they are expecting (Lilienfeld, Ammirtai, & [36] Landfield, 2009). Forensic psychologists are also working to reduce the incidence of false identification by helping police develop better procedures for interviewing both suspects and eyewitnesses (Steblay, Dysart, Fulero, & Lindsay, [37] 2001). Schemas help us remember new information but may also lead us to falsely remember things that never happened to us and to distort or misremember things that did. Consider a time when you were uncertain if you really experienced an event or only imagined it. How do these knowledge structures bias your information processing and behavior, and how might you prevent them from doing so? Imagine that you were involved in a legal case in which an eyewitness claimed that he had seen a person commit a crime. Based on your knowledge about memory and cognition, what techniques would you use to reduce the possibility that the eyewitness was making a mistaken identification? When dreams become a royal road to confusion: Realistic dreams, dissociation, and fantasy proneness. Memory for expectancy-congruent and expectancy-incongruent information: A review of the social and social developmental literatures. Children report suggested events even when interviewed in a non-suggestive manner: What are its implications for credibility assessment? Reconstruction of automobile destruction: An example of the interaction between language and memory. Changing beliefs about implausible autobiographical events: A little plausibility goes a long way. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 37(2), 225–233. The myth of repressed memory: False memories and allegations of sexual abuse (1st ed. Memory accessibility and probability judgments: An experimental evaluation of the availability heuristic. When less is more: Counterfactual thinking and satisfaction among Olympic medalists. When less is more: Counterfactual thinking and satisfaction among Olympic medalists. Witnesses to crime: Social and cognitive factors governing the validity of people’s reports. Giving debiasing away: Can psychological research on correcting cognitive errors promote human welfare? Eyewitness accuracy rates in sequential and simultaneous lineup presentations: A meta-analytic comparison. The cognitive school was influenced in large part by the development of the electronic computer. Explicit memory tests include recall memory tests, recognition memory tests, and measures of relearning (also known as savings). Implicit memory refers to the influence of experience on behavior, even if the individual is not aware of those influences. Implicit memory is made up of procedural memory, classical conditioning effects, and priming. Priming refers both to the activation of knowledge and to the influence of that activation on behavior. An important characteristic of implicit memories is that they are frequently formed and used automatically, without much effort or awareness on our part.

Examination by being narrowly interpreted as males always being in a male physician was culturally incongruent for the control buy 250mg flutamide overnight delivery medicine 666. Negative stereotypes held by nurses about women discount flutamide 250 mg amex symptoms kidney failure, so culture care negotiation and repatterning the Arab males’ reluctance to participate in the was essential for culturally congruent care purchase 250 mg flutamide visa symptoms dengue fever. Luna birth process were also discovered cheap 250 mg flutamide overnight delivery symptoms celiac disease, often presenting described the clinic as culturally decontextualized a barrier to giving nursing care. To counter this, for clients and their families because the prenatal Luna suggested the nurses use culture care preser- care and the environmental clinic context in which vation to maintain and support the generic culture the care was provided were not congruent with the care practices of men, which included surveillance, clients’ cultural values, beliefs, and practices (Luna, protection, and maintenance of the family. Luna discovered some dominant and uni- Still another finding from Luna’s study was the versal care constructs for Lebanese Muslim men, discovery of the importance of religious rituals to which included surveillance, protection, and main- many Muslim clients as an essential component of tenance of the family. For Lebanese women, the providing care within their cultural context (Luna, dominant and universal care constructs included 1989, 1994). Luna found that some Muslims pray emphasizing the positive attributes of educating three to five times a day, and others do not pray at the children and maintaining a family caring envi- all. During the culturalogical assessment (in the ronment according to the precepts of Islam. A hospital context), Luna suggested the nurse should number of generic or folk care practices were dis- ask about the client’s wishes regarding prayer. For instance, the female network in the an important cultural expression for their health Lebanese Muslim culture is very important at the and well-being. She also suggested that nurses prac- time of birth; Lebanese women come together to tice culture care accommodation for clients by ne- care for one another and offer practical and emo- gotiating with a social service organization that tional assistance for new immigrants who are served Arab clients in order to gather written and struggling to survive in a new cultural context such video materials in the Arabic language related to as the United States. Nurses should vation to maintain these generic care practices for avoid direct confrontation and spend considerable the health and well-being of clients. Many resi- cluding emphasizing the health and well-being of dents from both cultural groups participated in the both the mother and the baby. Residents assisted In 1999, Wehbeh-Alamah conducted a two-year other residents to the dining room, checked on oth- ethnonursing study using the culture care theory ers who did not appear for meals in the dining and studied the generic health-care beliefs, prac- room (care as surveillance of others), and assisted tices, and expressions of Lebanese American in ambulation of those who were not able to walk Muslim immigrants in two Midwestern U. This focus on other care versus only Her findings, which confirmed many of Luna’s self care was a form of culturally congruent care from 1989, included the discovery of specific that residents desired in order to maintain healthy generic folk care beliefs on practices that required and beneficial lifeways in an institutional setting. These included pro- staff as these generic care practices were integrated viding for prayer while facing east five times a day; into professional nursing care. Many African American residents desired spiritual or re- gender care findings were similar to those from ligious care and had some diverse aspects of such Luna’s study, revealing a persistence of many re- care rooted in their respective cultures. The find- lated care patterns over time as predicted in the ings of both universality and diversity within the culture care theory. However, the women in pattern of religious or spiritual care supported Wehbeh-Alamah’s study believed the absence of ex- Leininger’s theory, which states that “culture care tended family members in the United States had in- concepts, meanings, expressions, patterns, fluenced male family members’ thinking about the processes, and structural forms of care are different appropriateness of men caring for family members. Anglo American residents received a and participation in direct caregiving by Muslim more formal type of care from their churches, such men (Wehbeh-Alamah, in press). Currently, as a minister coming to the retirement home to Wehbeh-Alamah is conducting an ethnonursing do a worship service or a church choir traveling study of the culture care of Syrian American to the retirement home to entertain the residents. In addi- The nurses at the retirement home practiced tion to discovering the culture care meanings, be- culture care preservation by maintaining the in- liefs, and practices of this group, she will compare volvement of churches in the daily lives of both cul- this study with her previous studies to arrive at uni- tural groups to help residents face living in a versal and diverse care findings among Muslim im- retirement home with increasing disabilities related migrants from diverse cultures living in the United to aging and handicaps, and even dealing with the States. This study revealed their elderly relatives enhanced the health and life- care implications for nurses who practice in retire- ways of both Anglo and African American elders ment homes, nursing homes, apartments for the in the retirement home setting. In contrast with the Anglo In 2000, McFarland & Zehnder (in press) con- American findings, African American spouses, chil- ducted a two-year ethnonursing study of the cul- dren, extended family members, and nonkin who ture care of German American elders living in a were considered family reflected the care pattern of nursing home in a small Midwestern city in the families helping elderly residents. Their findings, which confirmed great grandchildren, nieces, nephews, grandnieces, many of McFarland’s (1997) earlier findings, in- and grandnephews, as well as church members or cluded many care beliefs and practices that required friends who were considered family and were re- culture care preservation. German American elder ferred to as brothers, sisters, or daughters, were in- care practices included caring for fellow residents volved in caring for African American elders. The by assisting confused residents to find their assigned nursing staff recognized the importance of family seat in the dining room or making items for the an- involvement in the care of residents and practiced nual bazaar to raise money to buy flowers for the culture care preservation to maintain culture spe- nursing home courtyard garden, thereby benefit- cific family care practices for residents from each ting all of the residents. Most African American resi- African American elders and was confirmed in this dents had left homes that were in unsafe neighbor- German American study. African American nursing staff recog- from the local German American church and pas- nized the importance of protective care and often tor. The pastor conducted a worship service and a accompanied African American residents when Bible class in German each week. The nursing staff made care, provided by connections with the Lutheran efforts to practice culture care accommodation by Church, was essential to German American elders negotiating to take the residents outside to sit on in maintaining their traditional lifeways and health the small grass strip around the perimeter of the in the nursing home setting. Professional nurses need to be more ac- ethnonursing studies of elder care conducted by tively involved in culture care repatterning as co- transcultural nurses with diverse cultures world- participants with elders to restructure lifeway wide. This will hopefully lead to the discovery of practices, care routines, and the environmental universal and diverse care meanings, beliefs, and context of nursing homes (including room designs practices to meet the needs of the increasing num- and privacy considerations). Culture care restruc- bers of elders worldwide who value generic culture- turing of these care-related concerns can only be specific care to reaffirm their cultural identities in accomplished when nurses assume an advocacy the latter phase of their lives. The culture care theory, with the ethnonursing method, assisted the researcher in The purpose of the culture care theory (along this study in the discovery of action and decision with the ethnonursing method) has been to modes that were culturally specific for Anglo and discover culture care with the goal of using African American elders residing in a long-term the knowledge to combine generic and care institution. The theory fo- culturally congruent nursing care using the cuses on a long-neglected area in nursing three modes of nursing actions and decisions practice—culture care—that is most relevant that is meaningful, safe, and beneficial to to our multicultural world. The clinical Universality is depicted in the sunrise enabler use of the three major care modes (culture as a rising sun. This visual metaphor is par- care preservation or maintenance; culture ticularly apt as the future of the culture care care accommodation or negotiation; and cul- theory shines brightly indeed, because it is ture care repatterning or restructuring) by holistic, comprehensive, and fits discovering nurses to guide nursing judgments, decisions, care related to diverse and similar cultures, and actions is essential in order to provide contexts, and ages of people in familiar and culturally congruent care that is beneficial, naturalistic ways. The theory is useful to satisfying, and meaningful to the people nurses and to nursing and to professionals in nurses serve. The studies of the four cultures other disciplines such as physical, occupa- just reviewed (Lebanese Muslim, Anglo tional, and speech therapy, medicine, social American, African American, and German work, and pharmacy. Health-care practition- Americans) substantiate that the three modes ers in other disciplines are beginning to use are care centered and are based on the use of this theory because they also need to become generic care (emic) knowledge along with knowledgeable about and sensitive and re- professional care (etic) knowledge obtained sponsible to people of diverse cultures who from research using the culture care theory need care (Leininger, 2002). This chapter has reviewed only a small selection of the culture care findings from ethnonursing research studies conducted over the past four References decades. Culture care expression, meanings, and experi- ings of interest to practicing nurses who care ences of pregnant Mexican American women within Leininger’s for clients of all ages from diverse and similar culture care theory. Mexican American women’s expressions of the tional and community contexts around the meaning of culturally congruent prenatal care. Nursing and anthropology: Two worlds to found in the Journal of Transcultural Nursing blend. Transcultural nursing presents an exciting (1989 to 2004) and in the numerous books challenge. Caring: The essence and central focus Nurses in clinical practice are advised to con- of nursing. Nursing Research Foundation Report, 12(1), sult a list of research studies and doctoral dis- 2–14. Care: Discovery and uses in clinical and cultural and general nursing knowledge with community nursing. Journal of Transcultural mained the strongest advocates of the culture Nursing, 1(1), 4–16. Part I: The theory of culture care and cessity to advance nursing knowledge and practices. Transcultural nursing: Concepts, theories, and practice (3rd Detroit: Wayne State University Press. Culture care diversity and universality: A study conceptualized within Leininger’s theory. Ethnonursing: A research method with American elderly residents within the environmental context of enablers to study the theory of culture care. Transcultural nursing: Concepts, theories, Nursing Science Quarterly, 10(4), 186–192. Overview and reflection of the theory of German American elders within a nursing home context.

During the acute phase of the infection purchase flutamide 250mg with mastercard symptoms 0f high blood pressure, approx 50% experience a seroconversion “flu-like” illness cheap 250 mg flutamide medicine while breastfeeding. The individual is infectious at this time purchase flutamide 250mg fast delivery symptoms kidney infection, because viral antigen (p24) is present in the blood discount 250 mg flutamide with amex treatment resistant anxiety. As antibodies start to form, the viral antigen disappears and the individual enters the latent phase. He or she is noninfectious and remains well for a variable period of time (7– 15 years). Routes of Transmission Parenteral transmission included needlestick injuries, bites, unscreened blood transfusions, tattooing, acupuncture, and dental procedures where equip- ment is inadequately sterilized. Risk of transmission is increased with deep penetrating injuries with hollow bore needles that are visibly bloodstained, Infectious Diseases 251 especially when the device has previously been in the source patient’s (con- tact) artery or vein. Other routes include mucous membrane exposure (eyes, mouth, and geni- tal mucous membranes) and contamination of broken skin. Therefore, people who have sustained penetrat- ing bite injuries can be reassured that they are not at risk, providing the con- tact was not bleeding from the mouth at the time. Risk of Seroconversion The risk from a single percutaneous exposure from a hollow bore needle is low, and a single mucocutaneous exposure is even less likely to result in infection. The risk from sexual exposure varies, although it appears that there is a greater risk with receptive anal intercourse compared with receptive vaginal intercourse (26). There is little or no risk from saliva, urine, vomit, or feces unless they are visibly bloodstained. Other fluids that constitute a theoretical risk include cere- brospinal, peritoneal, pleural, synovial, or pericardial fluid. Management in Custody of Staff/Victims in Contact With Disease Management in custody of staff/victims in contact with disease includes following the immediate management flow chart (Fig. There is no need for the forensic physician to go into details about the meaning of the test, but the contact should be encouraged to attend the geni- tourinary department (or similar) of the designated hospital to discuss the test results. Should the contact refuse to provide a blood sample, then any infor- mation about his or her lifestyle, ethnic origin, state of health, etc. Where only saliva is involved in a penetrating 252 Nicholson bite injury, there is every justification to reassure the victim that he or she is not at risk. Ideally, treatment should be started within an hour after exposure, although it will be considered for up to 2 weeks. Weekly examina- tions of the “victim” should occur during treatment to improve adherence, monitor drug toxicity, and deal with other concerns. Other useful information that may influence the decision whether to treat with the standard regimen or use alternative drugs includes interaction with other medications that the “victim” may be taking (e. During the second or third trimester, only Combivir would be used, because there is limited experience with protease inhibitors. Apply uni- versal precautions when dealing with the detainee, and ensure that contami- nated cells and/or bedding are managed appropriately. Epidemiology and Prevalence Cases of this highly infectious disease occur throughout the year but are more frequent in winter and early spring. In the United Kingdom, the highest prevalence occurs in the 4- to 10-years age group. A similar prevalence has been reported in other parts of Western Europe and the United States. In South East Asia, Varicella is mainly Infectious Diseases 253 a disease of adulthood (31). Therefore, people born in these countries who have moved to the United Kingdom are more likely to be susceptible to chicken pox. There is a strong correlation between a history of chicken pox and sero- logical immunity (97–99%). Most adults born and living in industrialized countries with an uncertain or negative history of chicken pox are also serop- ositive (70–90%). In March 1995, a live-attenuated vaccine was licensed for use in the United States and a policy for vaccinating children and susceptible health care personnel was introduced. In summer 2002, in the United King- dom, GlaxoSmithKline launched a live-attenuated vaccine called Varilrix. Any health care worker with no previous history of chicken pox should be screened for immunity, and if no antibodies are found, then they should receive two doses of vaccine 4–8 weeks apart. The vaccine is not currently recommended for children and should not be given during pregnancy. Incubation Period and Symptoms Following an incubation period of 10–21 days (this may be shorter in the immunocompromised), there is usually a prodromal “flu-like” illness before the onset of the rash. The lesions typically appear in crops, rapidly progressing from red papules through vesicles to open sores that crust over and separate by 10 days. In adults, the disease is often more severe, with lesions involving the scalp and mucous membranes of the oropharynx. Complications In children, the disease is often mild, unless they are immunocompro- mised, so they are unlikely to experience complications. Usually, this is limited to bleeding into the skin, but life- threatening melena, epistaxis, or hematuria can occur. Varicella pneumonia ranges from patchy lung consolidation to overt pneumonitis and occurs in 1 in 400 cases (33). It can occur in previously healthy individuals (particularly adults), but the risk is increased in those who smoke. It runs a fulminating course and is the most common cause of Vari- cella-associated death. Any suspicion of lung involvement is an indica- tion for immediate treatment, and any detainee or staff member should be sent to hospital. Involvement of the central nervous system includes several condi- tions, including meningitis, Guillain-Barre, and encephalitis. Period of Infectivity This is taken as 3 days before the first lesions appear to the end of new vesicle formation and the last vesicle has crusted over. Routes of Transmission The primary route is through direct contact with open lesions of chicken pox. However, it is also spread through aerosol or droplets from the respiratory tract. Chicken pox may also be acquired through contact with open lesions of shingles (Varicella zoster), but this is less likely because shingles is less infec- tious than chicken pox. Approximately 10% of the adult population born in the United Kingdom and less than 5% of adults in the United States fall into this category. Therefore, it is more likely that if chicken pox is encountered in the custodial setting, it will involve people born outside the United Kingdom (particularly South East Asia) or individu- als who are immunocompromised and have lost immunity. Pneumonia can occur in up to 10% of pregnant women with chicken pox, and the severity is increased in later gestation (34). If infection is acquired in the first 20 weeks, there is a less than 3% chance of it leading to congenital Varicella syndrome. Infection in the last trimester can lead to neonatal Varicella, unless more than 7 days elapse between onset of maternal rash and delivery when antibodies have time to cross the placenta leading to either mild or inapparent infection in the newborn. Management in Custody Staff with chicken pox should stay off work until the end of the infective period (approx 7–14 days). Those in contact with disease who are known to be nonimmune or who have no history of disease should contact the designated occupational health physician. Detainees with the disease should not be kept in custody if at all possible (especially pregnant women). If this is unavoidable, then nonimmune or immunocompromised staff should avoid entering the cell or having close con- tact with the detainee. Aciclovir (or similar antiviral agent) should be given as soon as possible to people who are immunocompromised with chicken pox. It should also be considered for anyone over 15 years old because they are more likely to develop complications.

Studies show that it reduces the amount of sugar absorbed from starchy meals order 250mg flutamide with amex medicine 1900s spruce cough balsam fir, lowers after-meal blood sugar levels generic flutamide 250 mg with amex symptoms in early pregnancy, and promotes fat loss flutamide 250mg low price medicine 6 times a day. Complementary Supplements Fibre supplements: Help reduce appetite and cravings generic flutamide 250mg with amex medications during breastfeeding, improve blood sugar balance, and promote weight loss. There are no serious side effects; however, high amounts of caffeine may cause restlessness, insomnia, and increased heart rate in some individuals. Suntheanine: An amino acid present in green tea that may help with weight loss by con- trolling appetite, cravings, and stress-related eating. Develop a regular exercise program, including cardiovascular and resistance activi- ties and stretching. Eat small, frequent meals with quality proteins, high-fibre carbohydrates, and good fats. The disease is caused by wear and tear on the joints and deterioration of joint cartilage, which is a gel-like material that covers and protects the ends of bones. As the cartilage breaks down, we lose the cushion that it provides between our bones. As a result, the bones start to rub against each other, causing a grinding or clicking of the joints, bone damage, inflammation, and pain. As the disease progresses, the pain O can become severe and affect one’s mobility and quality of life. In others the condition progresses as the joint deteriorates and inflammation sets in. They do not prevent joint damage, and can actually accelerate cartilage breakdown. There are numerous 346 serious side effects, including stomach ulcers and bleeding, diarrhea, stomach pain, kidney and liver problems, and worsening of heart failure. Corticosteroids, such as cortisone, are injected into the joint to relieve severe inflammation. These drugs are used only for severe cases, and for the short term because they can damage cartilage and remove minerals from the bone, further weakening the joint. Viscosupplementation involves a clear gel-like substance that is injected into the joint to lubricate the cartilage, which helps to reduce pain and improve mobility. O Arthroscopic procedures to remove loose bone fragments or a joint replacement (with a plastic, ceramic, or metal joint) may be done for severe cases. Foods to avoid: • Nightshade vegetables (potatoes, tomatoes, peppers, eggplant) contain a substance called solanine, which can trigger pain and inflammation; preliminary studies have found benefits in avoiding these foods. Take a load off and rest when doing heavy or repeated tasks such as gardening, shovelling snow, or doing housework. Do a combination of strength-training exercises (work with light weights and machines), low-impact cardiovascular activities (swimming, walking), and stretching. Top Recommended Supplements Celadrin: A blend of fatty acids that reduces inflammation and pain, lubricates joints, and promotes healing. It enhances the shock- absorbing properties of collagen and blocks enzymes that break down cartilage. Glucosamine: A major component of joint cartilage that provides building blocks for growth, repair, and maintenance of cartilage; helps cartilage absorb water; and keeps joints lubricated. It is well tolerated; however, it may thin the blood, so use cautiously along with blood-thinning medications. Curcumin: An antioxidant that has been shown in studies to have anti-inflammatory effects comparable to cortisone. Essential fatty acids: Both the omega-3s (fish oil) and omega-6s (borage, primrose oil) help to reduce the pain and inflammation and lubricate the joints. Minimize red meat, dairy, sugar, and refined/processed foods; avoid nightshade foods. Do light strength training and cardiovascular and stretching activities regularly to improve joint function and mobility and to reduce pain. Bone is living tissue that consists of a matrix of protein fibres (collagen), hard- ened with calcium, phosphorus, magnesium, zinc, copper, and other minerals. An interconnecting structure gives bone its strength: on the outside there is a tough, O dense rind of cortical bone, and on the inside there is spongy-looking trabecular bone. Bone cells called osteoclasts are constantly breaking down old bone at the same time that other cells, called osteoblasts, are building new bone. The activity of these cells is regulated primarily by the hormones estrogen, testosterone, and parathyroid hormone. Until about age 24, there is a balance in activity of osteoclasts and osteoblasts. After that point, bone loss begins, and as we age more bone is broken down than is replaced. In women, the rate of loss accelerates for several years after menopause, and then slows again. The trabecular bone normally looks like a honeycomb, but in those with osteopo- rosis the spaces in that honeycomb grow larger because more bone is destroyed than replaced. There are many factors that contribute to and accelerate bone loss, and much that can be done to prevent this disease. Since bone health affects our mobility and ability to carry out daily activities, it is important to learn how to prevent osteoporosis and maintain strong, healthy bones throughout life. Once the bones have become weakened, osteoporosis may cause back pain, collapsed vertebrae, loss of height, and spinal deformities. For those with osteoporosis or osteopenia with strong risk factors for osteoporosis, drug therapy may be recommended to either slow the rate of bone loss or promote bone development. There are a variety of medications that doctors prescribe, such as hormones and bisphosphonates (such as etidronate). Examples include canned fish with bones (salmon and sardines), dark-green vegetables (kale, kelp, collards, broccoli, and Brussels sprouts), and calcium-fortified orange juice and soy milk. Some studies have shown that people who get their calcium from plant sources have lower rates of osteoporosis. Many people have difficulty digesting lactose, the sugar in milk, and some are allergic to the protein in milk. Another concern is that dairy cows can be injected with hormones and antibiotics, which pass into their milk. Those who can tolerate milk should choose fat-free, organic milk and cheese to avoid ingestion of these substances. Recent research suggests that polyphenols (plant pigments) in fruits, vegetables, green tea, and red wine have a positive effect on bone-building cells. Food sources include leafy green vegetables, whole grains, nuts, seeds, meat, milk, soybeans, tofu, legumes, and figs. Food sources include fortified milk products and breakfast cereals, fatty fish, and eggs. O • Soy foods such as tofu, soy milk, roasted soy beans, soy powders, and soy bars can also play a role in the prevention of osteoporosis. Soy contains isoflavones, which are plant- based estrogens that protect against bone loss. Foods to avoid: • Caffeine (more than three cups coffee per day) or sodium can increase calcium loss through urination, accelerating bone deterioration. Lifestyle Suggestions • Weight-bearing activities, which place stress on the bone, help to strengthen bones and improve bone density. Exercise also increases muscle strength, coordination, and balance, helping to preserve mobility and reduce the risk of injury and fracture. Top Recommended Supplements Calcium: Essential for bone health; since it may not be possible to get adequate amounts through diet, supplements may be necessary. Recommended intake for men and women ages 19–50 is 1,000 mg daily and 1,500 mg over age 50. Many products combine calcium with other nutrients for bone health such as vitamin D and magnesium.

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