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By W. Ivan. Hofstra University.

An adequate database is necessary for the development of an effective teaching plan sildalis 120 mg sale erectile dysfunction pills cape town. These feelings may have been suppressed or repressed for a very long time and their disclosure will undoubtedly be a pain- ful experience generic sildalis 120 mg without a prescription erectile dysfunction 9 code. Verbalization of feelings in a nonthreatening environment may help client come to terms with long-unresolved issues discount 120mg sildalis with amex erectile dysfunction drug coupons. Have client keep a diary of appearance sildalis 120 mg fast delivery erectile dysfunction protocol formula, duration, and intensity of physical symptoms. A separate record of situations that the client finds especially stressful should also be kept. Compari- son of these records may provide objective data from which to observe the relationship between physical symptoms and stress. Change cannot occur until the client realizes that physical symp- toms are used to fulfill unmet needs. Discuss the importance of recognizing the differences among passive, assertive, and aggressive behaviors, and of respecting the human rights of others while protecting one’s own basic human rights. Use of these techniques enhances self-esteem and facilitates client’s interpersonal relationships. Discuss adaptive methods of stress management: relaxation techniques, physical exercise, meditation, breathing exer- cises, or mental imagery. These techniques may be employed in an attempt to relieve anxiety and discourage the use of physical symptoms as a maladaptive response. Client verbalizes an understanding of the relationship between psychological stress and physical symptoms. Client demonstrates the ability to use therapeutic techniques in the management of stress. During periods of intoler- able stress, the individual blocks off part of his or her life from consciousness. The stressful emotion becomes a separate entity, as the individual “splits” from it and mentally drifts into a fan- tasy state. Dissociative Amnesia: An inability to recall important per- sonal information, usually of a traumatic or stressful nature. The extent of the disturbance is too great to be explained by ordinary forgetfulness. Localized Amnesia: Inability to recall all incidents asso- ciated with a traumatic event for a specific time period following the event (usually a few hours to a few days). Selective Amnesia: Inability to recall only certain incidents associated with a traumatic event for a specific period fol- lowing the event. Continuous Amnesia: Inability to recall events subse- quent to a specific time up to and including the present. Systematized Amnesia: With this type of amnesia, the individual cannot remember events that relate to a specific category of information, such as one’s family, or to one particular person or event. A sudden, unexpected travel away from home or customary work locale with assumption of a new identity and an inability to recall one’s previous identity. The existence with- in the individual of two or more distinct personalities, each of which is dominant at a particular time. The original person- ality usually is not aware (at least initially) of the existence of subpersonalities. When there are more than two subperson- alities, however, they are usually aware of each other. Transi- tion from one personality to another is usually sudden and often associated with psychosocial stress. Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, feelings of detachment from the environment, or a sense of observing oneself from outside the body. Some clinicians have suggested a possible correlation between neurological alterations and dissocia- tive disorders. Although available information is inadequate, it is possible that dissociative amnesia and dissociative fugue may be related to alterations in certain areas of the brain that have to do with memory. These include the hippocam- pus, mammillary bodies, amygdala, fornix, thalamus, and frontal cortex. Freud (1962) believed that dis- sociative behaviors occurred when individuals repressed distressing mental contents from conscious awareness. He believed that the unconscious was a dynamic entity in which repressed mental contents were stored and unavail- able to conscious recall. Current psychodynamic explana- tions of dissociation are based on Freud’s concepts. These experiences usually take the form of severe physical, sexual, and/or psychological abuse by a parent or significant other in the child’s life. It has been sug- gested that the number of an individual’s alternate per- sonalities may be related to the number of different types of abuse he or she suffered as a child. Individuals with many personalities have usually been severely abused well into adolescence. Sudden travel away from familiar surroundings; assumption of new identity, with inability to recall past. Assumption of additional identities within the personality; behavior involves transition from one identity to another as a method of dealing with stressful situations. Common Nursing Diagnoses and Interventions (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Client will verbalize understanding that he or she is employ- ing dissociative behaviors in times of psychosocial stress. Client will verbalize more adaptive ways of coping in stress- ful situations than resorting to dissociation. Long-term Goal Client will demonstrate ability to cope with stress (employing means other than dissociation). Presence of a trusted individual provides feeling of security and assurance of freedom from harm. This infor- mation is necessary to the development of an effective plan of client care and problem resolution. Help client understand that the disequilibrium felt is acceptable—indeed, even expected—in times of se- vere stress. Client’s self-esteem is preserved by the knowl- edge that others may experience these behaviors in similar circumstances. As anxiety level decreases (and memory returns), use explo- ration and an accepting, nonthreatening environment to encourage client to identify repressed traumatic experiences that contribute to chronic anxiety. Have client identify methods of coping with stress in the past and determine whether the response was adaptive or Dissociative Disorders ● 195 maladaptive. In times of extreme anxiety, client is unable to evaluate appropriateness of response. This information is necessary for client to develop a plan of action for the future. Assist cli- ent in the selection of those that are most appropriate for him or her. Depending on current level of anxiety, client may require assistance with problem-solving and decision- making. Positive reinforcement enhances self-esteem and encourages repetition of desired behaviors.

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For example: 1 If the different components of the self-regulatory model interact order sildalis 120mg with amex impotence treatment natural, should they be measured separately? For example purchase sildalis 120 mg amex erectile dysfunction urologist, is the belief that an illness has no serious consequences an illness cognition or a coping strategy? For example cheap sildalis 120mg erectile dysfunction overweight, is the appraisal that symptoms have been reduced a successful outcome or is it a form of denial (a coping strategy)? The individual processes involved in the self-regulatory model will now be examined in greater detail generic sildalis 120mg otc erectile dysfunction pills dischem. However, symptom perception is not a straightforward process (see Chapter 12 for details of pain perception). For example, what might be a sore throat to one person could be another’s tonsillitis and whereas a retired person might consider a cough a serious problem a working person might be too busy to think about it. Pennebaker (1983) has argued that there are individual differences in the amount of attention people pay to their internal states. For example, Pennebaker (1983) reported that individuals who were more focused on their internal states tended to overestimate changes in their heart rate compared with subjects who were externally focused. Being internally focused has also been shown to relate to a perception of slower recovery from illness (Miller et al. Being internally focused may result in a different perception of symptom change, not a more accurate one. Mood, cognitions, environment and symptom perception Skelton and Pennebaker (1982) suggested that symptom perception is influenced by factors such as mood, cognitions and the social environment. Mood: The role of mood in symptom perception is particularly apparent in pain perception with anxiety increasing self-reports of the pain experience (see Chapter 12 for a discussion of anxiety and pain). In addition, anxiety has been proposed as an explanation for placebo pain reduction as taking any form of medication (even a sugar pill) may reduce the individual’s anxiety, increase their sense of control and result in pain reduction (see Chapter 13 for a discussion of anxiety and placebos). In an experimental study, participants were exposed to low intensity somatic sensations induced by breathing air high in carbon dioxide. They were then told that the sensation would be either positive, negative or somewhere between and were asked to rate both the pleasantness and intensity of their symptoms. The results showed that what the participants were told about the sensation influenced their ratings of its pleasantness. The results also showed that although people who rated high on negative affectivity showed similar ratings of pleasantness to those low on negative affectivity they did report more negative meanings and worries about their symptoms. This indicates that expectations about the nature of a symptom can alter the experience of that symptom and that negative mood can influence the attributions made about a symptom. Cognition: An individual’s cognitive state may also influence their symptom per- ception. This is illustrated by the placebo effect with the individual’s expectations of recovery resulting in reduced symptom perception (see Chapter 13). Ruble (1977) carried out a study in which she manipulated women’s expectations about when they were due to start menstruating. She gave sub- jects an ‘accurate physiological test’ and told women either that their period was due very shortly or that it was at least a week away. Pennebaker also reported that symptom perception is related to an individual’s attentional state and that boredom and the absence of environmental stimuli may result in over-reporting, whereas distraction and attention diversion may lead to under-reporting (Pennebaker 1983). Sixty-one women who had been hospitalized during pre-term labour were randomized to receive either information, distraction or nothing (van Zuuren 1998). The results showed that distraction had the most beneficial effect on measures of both physical and psychological symptoms suggesting that symptom per- ception is sensitive to attention. Symptom perception can also be influenced by the ways in which symptoms are elicited. For example, Eiser (2000) carried out an experimental study whereby students were asked to indicate their symptoms, from a list of 30 symp- toms, over the past month and the past year and also to rate their health status. The results showed that those in the ‘exclude’ condition reported 70 per cent more symptoms than those in the ‘endorse’ condition. In addition, those who had endorsed the symptoms rated their health more negatively than those who had excluded symptoms. This suggests that it is not only focus and attention that can influence symptom perception but also the ways in which this focus is directed. These different factors are illustrated by a condition known as ‘medical students’ disease’, which has been described by Mechanic (1962). A large component of the medical curriculum involves learning about the symptoms associated with a multitude of different illnesses. More than two-thirds of medical students incorrectly report that at some time they have had the symptoms they are being taught about. Perhaps this phenomena can be understood in terms of: s Mood: medical students become quite anxious due to their workload. This anxiety may heighten their awareness of any physiological changes making them more internally focused. Therefore, symptom perception influences how an individual interprets the problem of illness. This may come in the form of a formal diagnosis from a health professional or a positive test result from a routine health check. However, screening and health checks may detect illness at an asymptomatic stage of development and therefore attendance for such a test may not have been moti- vated by symptom perception. Information about illness may also come from other lay individuals who are not health professionals. Before (and after) consulting a health professional, people often access their social network, which has been called their ‘lay referral system’ by Freidson (1970). This can take the form of colleagues, friends or family and involves seeking information and advice from multiple sources. For example, coughing in front of one friend may result in the advice to speak to another friend who had a similar cough, or a suggestion to take a favoured home remedy. Alternatively, it may result in a lay diagnosis or a suggestion to seek professional help from the doctor. Such social messages will influence how the individual interprets the ‘problem’ of illness. This section will examine three approaches to coping with illness: (1) coping with a diagnosis; (2) coping with the crisis of illness; and (3) adjustment to physical illness and the theory of cognitive adaptation. These different theoretical approaches have implications for understanding the differences between adaptive and maladaptive coping, and the role of reality and illusions in the coping process. They therefore have different implications for understanding the outcome of the coping process. Coping with a diagnosis Shontz (1975) described the following stages of coping that individuals often go through after a diagnosis of a chronic illness: s Shock: initially, according to Shontz most people go into a state of shock following a diagnosis of a serious illness. Being in shock is characterized by being stunned and bewildered, behaving in an automatic fashion and having feelings of detachment from the situation. This is characterized by disorganized thinking and feelings of loss, grief, helplessness and despair. Shontz argued that this stage is characterized by denial of the problem and its implications and a retreat into the self. According to Shontz, retreat is only a temporary stage and denial of reality cannot last for ever. Therefore, the retreat stage acts as a launch pad for a gradual reorientation towards the reality of the situation and as reality intrudes the individual begins to face up to their illness. Therefore, this model of coping focuses on the immediate changes following a diagnosis, suggesting that the desired outcome of any coping process is to face up to reality and that reality orientation is an adaptive coping mechanism. Coping with the crisis of illness In an alternative approach to coping with illness, Moos and Schaefer (1984) have applied ‘crisis theory’ to the crisis of physical illness. Crisis theory has been generally used to examine how people cope with major life crises and transitions and has traditionally provided a framework for understanding the impact of illness or injury. The theory was developed from work done on grief and mourning and a model of developmental crises at transition points in the life cycle.

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A healthy diet and lifestyle can help support proper immune function and reduce the risk of developing ear infections safe sildalis 120mg erectile dysfunction medication covered by insurance. Statistics show that three out of four children younger than three have had at least one ear infection order sildalis 120mg line erectile dysfunction of diabetes. When this happens generic sildalis 120 mg line zma erectile dysfunction, the skin inside the ear becomes watery order 120 mg sildalis free shipping erectile dysfunction pills list, reducing the natural acidity that fights incoming pathogens and infection may result. Swimmer’s ear usually clears up on its own, but requires a trip to the doctor if there is pain. For infants older than six months who are otherwise healthy and have mild symptoms, it is recommended to just keep an eye on your child for 72 hours. Once symptoms are detected, the ear infection is treated with a course of antibiotics to avoid complica- tions. For severe cases where a child has recurrent ear infections, surgery may be rec- ommended to place small tubes inside the ears to drain fluid and relieve pressure. The concern is that hearing loss from chronic ear infections may delay language and speech development. Children are under general anaesthesia during surgery, and usually recover quickly with little pain. There are maintenance issues and minor complications that may result from ear tubes, so it is important to discuss all factors with your doctor before proceeding with surgery. Children involved in this long-term study were followed from approximately age three to age 11. Over the years, the researchers tested the children for reading, writing, spelling, behavioural issues, social skills, and intelligence, and found that there 214 was no significant difference between the two groups. As a result of this groundbreaking study, guidelines regarding the treatment of chronic ear infections with tubes were re- evaluated and changed to encourage a watchful, waiting approach to treatment. E • Chewing gum that contains xylitol (a natural sugar found in some fruits) can help reduce the risk of ear infections. Studies have shown that xylitol interferes with the growth of some bacteria that may cause ear infections. Foods to avoid: • Dairy products may increase the risk of infection in those with sensitivities or allergies to cow’s milk. Top Recommended Supplements Echinacea: Can help to reduce the severity and duration of cold symptoms, which may help to prevent ear infections from developing, although this has not been specifically studied. Dosage: 1–2 mL (depending on age) of echinacea tincture taken three times per day or more. Echinacea should be started as soon as symptoms appear and continued until a few days after they are gone. Studies have shown that aged garlic extract can destroy the major bacteria that cause ear infections. Dosage: Adults should take two to six capsules daily; children should take one or two capsules daily. Complementary Supplements Oil of oregano: Has antibacterial and antifungal properties. Vitamin C: Helps support immune function and reduces the severity of cold symptoms. Dosage: Adults should take 1,000 mg; children should take 250–500 mg three times daily. Encourage a healthy diet, including lots of vegetables, fruits, whole grains, fish, flaxseed, yogurt, and chewing gum with xylitol. Aged garlic ex- tract can help support immune function and protect against infections. Eczema affects about six million Cana- dians and is the most common skin problem in children under the age of 12. There are several forms of eczema, including: Atopic dermatitis: Atopic dermatitis is the most common form of eczema, affecting about 10 percent of all Canadians. It usually begins in infancy and varies in severity during childhood and adolescence. It is thought to be due to a combination of dry, irritable skin and a malfunction in the body’s immune system. Contact dermatitis: This is caused by exposure to an irritant or allergen, such as laundry soap, dyes, cosmetics and skin products, cleaning products, or plants (poison ivy). E Neurodermatitis: This form develops in areas where something, such as tight cloth- ing, rubs or scratches your skin and causes an irritation. Seborrheic dermatitis: Seborrheic dermatitis is a red rash with yellowish and oily scales, which is known as cradle cap when it affects infants. It may also affect adults and can be triggered by stress or other health conditions such as Parkinson’s disease. Stasis dermatitis: This may be caused by varicose veins and chronic venous insuffi- ciency, which cause a buildup of fluid beneath the skin of the legs. This fluid buildup interferes with your blood’s ability to nourish your skin and places extra pressure against the skin. While eczema can be uncomfortable to deal with, it is not contagious and can be managed well with a variety of conventional and natural methods. Symptoms vary in severity and include: • Dryness • Itching • Redness • Skin lesions (crusty, scaly patches) • Swelling In severe cases, fluid-filled vesicles, ulcers, or cracks may occur. If the skin becomes red and warm to the touch, it may be infected and require immediate medical attention. Eczema flare-ups can also be triggered by food additives (preservatives and E dyes) and spices. These products should not be used over the long term, as they may cause side effects such as burning, itching, blis- tering, easy bruising, and thinning of skin. Elidel (pimecrolimus) is a drug that affects the immune system and helps reduce flare-ups. Pumpkin and sunflower seeds also con- tain zinc, which is important for skin health. Foods to avoid: • Spices, dairy, caffeine, alcohol, and chemicals present in processed and fast foods may trig- ger flare-ups. Note: Since food allergies can cause eczema, consider an elimination diet (see Appendix D) to determine if dairy, wheat, or other common allergens are the source of your skin problems. Lifestyle Suggestions If you have contact dermatitis, avoid exposure to known irritants. For all forms of eczema, the following tips can help reduce flare-ups: • Use only hypoallergenic skin products, soaps, and detergents and rinse well with water. Look for creams that are thick and emollient and contain one or more of the following: chamomile; vitamins A, E, and C; calendula; licorice; and lavender. Complementary Supplements Celadrin: A mixture of fatty acids that reduce inflammation. Probiotics: Beneficial bacteria with immune-regulating properties; help improve digestion and reduce allergic reactions. Witch hazel: An astringent that helps dry up weeping eczema and reduces itching and inflammation. Probiotics may be helpful for those with digestive problems and to reduce allergic responses. However, because there is nowhere for this blood to exit the body, it becomes trapped, irritates surrounding tis- sue, and may cause scar tissue to form, which is painful. The actual cause is unknown; however, it is known that endometriosis is an estrogen- dependent condition and estrogen is necessary to induce or maintain endometriosis.

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