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Observational assessment Observational assessments attempt to make a more objective assessment of pain and are used when the patients’ own self-reports are considered unreliable or when they are unable to provide them discount 50mg azathioprine fast delivery. For example generic 50mg azathioprine with amex, observational measures would be used for children cheap 50mg azathioprine amex, some stroke suﬀerers and some terminally ill patients. Observational measures include an assessment of the pain relief requested and used, pain behaviours (such as limping, grimacing and muscle tension) and time spent sleeping and/or resting. Physiological measures Both self-report measures and observational measures are sometimes regarded as unreliable if a supposedly ‘objective’ measure of pain is required. In particular, self- report measures are open to the bias of the individual in pain and observational measures are open to errors made by the observer. Such measures include an assess- ment of inﬂammation and measures of sweating, heart rate and skin temperature. However, the relationship between physiological measures and both observational and self-report measures is often contradictory, raising the question ‘Are the indi- vidual and the rater mistaken or are the physiological measurements not measuring pain? However, the gate control theory, developed in the 1960s and 1970s by Melzack and Wall, included psychological factors. As a result, pain was no longer understood as a sensation but as an active perception. Due to this inclusion of psychological factors into pain perception, research has examined the role of factors such as learning, anxiety, fear, catastrophizing, meaning, attention and pain behaviour in either decreasing or exacerbating pain. As psychological factors appeared to have a role to play in eliciting pain perception, multi- disciplinary pain clinics have been set up to use psychological factors in its treatment. Recently, researchers have suggested a role for pain acceptance as a useful outcome measure and some research indicates that acceptance, rather than coping might be a better predictor of adjustment to pain and changes following treatment. Early models of pain regarded the physical aspects of pain as ‘real’ and categorized pain as either ‘organic’ or ‘psychogenic’. Such models con- ceptualized the mind and body as separate and conform to a dualistic model of individuals. Recent models of pain have attempted to integrate the mind and the body by examining pain as a perception that is inﬂuenced by a multitude of diﬀerent factors. However, even within these models the mind and the body are still regarded as separate. It is often assumed that changes in theoretical perspective over time represents improvement with the recent theories reﬂecting a better approximation to the truth of ‘what pain really is’. However, perhaps these diﬀerent theories can also be used themselves as data to show how psychologists have thought in the past and how they now think about individuals. For example, in the past pain was seen as a passive response to external stimuli; therefore, individuals were seen as passive responders. However, today pain is increasingly seen as a response to the individual’s self-control – pain is a sign of either successful or failed self-control. Therefore, contemporary individuals are seen as having self-control, self-management and self-mastery. Perhaps the diﬀerent theories over time reﬂect diﬀerent (not necessarily better) versions of individuality. This book provides a comprehensive and critical overview of the complex area of pain assessment. This edited collection provides a detailed account of contemporary approaches to treating pain. This edited collection provides an excellent overview of how pain can be measured and the problems inherent within pain assessment. This paper examines how theories of pain perception can be used to reduce the pain experience. This chapter examines problems with deﬁning placebos and then assesses the different theories concerning how they work, highlighting the central role for patient expectations. It then outlines the implications of placebos for the different areas of health psychology discussed in the rest of this book, such as health beliefs and illness cognitions, health behaviours, stress, pain and illness and places this within a discussion of the relationship between the mind and body and the interrelationship between beliefs, behaviour and health and illness. Placebos have been deﬁned as follows: s Inert substances which cause symptom relief (e. For example, ‘My head- aches went after the operation, is this an unreal eﬀect (it wasn’t predicted) or a real eﬀect (it deﬁnitely happened)? For example, ‘I speciﬁcally went for cognitive restructuring therapy and ended up simply feeling less tired. For example, medicines such as wild animal faeces and the blood of a gladiator were supposed to increase strength, and part of a dolphin’s penis was supposed to increase virility. These so-called ‘medicines’ have been used at diﬀerent times in diﬀerent cultures but have no apparent medical (active) properties. In addition, treatments such as bleeding by leeches to decrease fever or travelling to religious sites such as Lourdes in order to alleviate symptoms have also continued across the years without any obvious understanding of the processes involved. Faith healers are another example of inert treatments ranging from Jesus Christ, Buddha and Krishna. The tradition of faith healers has persisted, although our understanding of the processes involved is very poor. Such apparently inert interventions, and the traditions involved with these practices, have lasted over many centuries. In addition, the people involved in these practices have become famous and have gained a degree of credibility. Perhaps, the maintenance of faith both in these interven- tions and in the people carrying out the treatments suggests that they were actually successful, giving the treatments themselves some validity. It is possible that there are medically active substances in some of these traditional treatments that were not understood in the past and are still not understood now (e. It is also possible that the eﬀectiveness of some of these treatments can be understood in terms of modern-day placebo eﬀects. Modern-day placebos Recently placebos have been studied more speciﬁcally and have been found to have a multitude of eﬀects. For example, placebos have been found to increase performance on a cognitive task (Ross and Buckalew 1983), to be eﬀective in reducing anxiety (Down- ing and Rickles 1983), and Haas et al. Beecher (1955), in an early study of the speciﬁc eﬀects of placebos in pain reduction, suggested that 30 per cent of chronic pain suﬀerers show relief from a placebo when using both subjective (e. They reported that half the subjects with angina pain were given a sham operation, and half of the subjects were given a real heart bypass operation. The results indicated that pain reduction in both groups was equal, and the authors concluded that the belief that the individual had had an operation was suﬃcient to cause pain reduction and alleviation of the angina. Since the 1940s, research into the eﬀectiveness of drugs has used randomized controlled trials and placebos to assess the real eﬀects of a drug versus the unreal eﬀects. However, if placebos have a multitude of eﬀects as discussed above, perhaps, rather than being taken out they should be seen as central to health status. If placebos have a multiple number of possible eﬀects, what factors actually mediate these changes? Several theories have been developed to try and understand the process of placebo eﬀects. Non-interactive theories Characteristics of the individual Individual trait theories suggest that certain individuals have characteristics that make them susceptible to placebo eﬀects. Such characteristics have been described as emotional dependency, extraversion, neurosis and being highly suggestible.
Rogers: tice-level theory of sleeping generic azathioprine 50mg, waking order 50mg azathioprine mastercard, and beyond waking Her life and her work (pp order azathioprine 50 mg with mastercard. Visions: The Journal of Rogerian Nursing Science, Nursing Science Quarterly, 2, 5–6. Rogers and her work experience, human ﬁeld motion, and time experience in older (pp. Unpublished doctoral dissertation, New York the Education Violet, the New York University newspaper, University, New York. Previous works include Nursing Fundamentals (1974); Man-Living-Health: A Rosemarie Rizzo Parse is professor and Niehoff Theory of Nursing (1981); Nursing Research: chair at Loyola University in Chicago. She is Qualitative Methods (1985); Nursing Science: Major founder and editor of Nursing Science Quarterly; Paradigms, Theories, and Critiques (1987); president of Discovery International, Inc. The body-mind-spirit nurse scholars in Australia, Canada, Denmark, perspective is particulate—focusing on the bio- Finland, Greece, Italy, Japan, South Korea, Sweden, psycho-social-spiritual parts of the whole human the United Kingdom, the United States, and other as the human interacts with and adapts to the envi- countries on ﬁve continents. Parse is a graduate of Duquesne University in psychological, social, and spiritual well-being. This Pittsburgh, and she received her master’s and doc- ontology leads to research and practice on phe- torate from the University of Pittsburgh. She was on nomena related to preventing disease and main- the faculty of the University of Pittsburgh, was dean taining and promoting health according to societal of the Nursing School at Duquesne University, and norms. In contrast, the unitary perspective is a view from 1983 to 1993 was professor and coordinator of of the human-universe process as irreducible, un- the Center for Nursing Research at Hunter College predictable, and ever-changing. It is not a static state but, rather, is ever-changing as the human chooses ways of living. This ontology leads Introducing the Theory: to research and practice on patterns (Rogers, 1992), The Human Becoming lived experiences, and quality of life (Parse, 1981, School of Thought 1992, 1997a, 1998a). Because the ontologies of these paradigmatic perspectives lead to different re- Presently, nurse leaders in research, administration, search and practice modalities, they lead to differ- education, and practice are focusing attention on ent professional services to humankind. The goal of the discipline is to expand knowledge The profession of nursing consists of people edu- about human experiences through creative concep- cated according to nationally regulated, deﬁned, and tualization and research. The standards and regulations are to preserve the safety of health care for members of society. The nursing regulations and standards are Knowledge of the discipline is the scientiﬁc speciﬁed predominantly in medical/scientiﬁc terms. This is according to tradition and is largely related to nursing’s early subservience to medicine. The the nurse leaders in health-care systems and in regu- discipline-speciﬁc knowledge is given birth and lating organizations have been developing standards fostered in academic settings where research and ed- (Mitchell, 1998) and regulations (Damgaard & ucation move the knowledge to new realms of un- Bunkers, 1998) consistent with discipline-speciﬁc derstanding. The goal of the profession is to provide knowledge as articulated in the theories and frame- service to humankind through living the art of the works of nursing. Members of the nursing profession are re- ment that will fortify the identity of nursing as a sponsible for regulating the standards of practice discipline with its own body of knowledge—one and education based on disciplinary knowledge that that speciﬁes the service that society can expect from reﬂects safe health service to society in all settings. The totality paradigm frameworks and Human Becoming language is unique to nursing. Nurses living the beliefs of this nine concepts written in verbal form with “ing” paradigm are concerned with participation of per- endings to make clear the importance of the ongo- sons in health-care decisions but have speciﬁc ing process of change as basic to human-universe regimes and goals to bring about change for the emergence. Nurses living the simultaneity unitary beings, as speciﬁed in the ontology, pre- paradigm beliefs hold people’s perspectives of their cludes any use of terms such as physiological, bio- health situations and their desires to be primary. Human Becoming, a school of thought named such The assumptions of the human becoming school of because it encompasses on ontology, epistemology, thought are written at the philosophical level of and methodologies, emanates from the simultane- discourse (Parse, 1998a). When the term (Rogers, 1992) and from existential phenomeno- “mankind” was replaced with “male gender” in the logical thought (Parse, 1981, 1992, 1994a, 1995, dictionary deﬁnition of “man,” the name of the 1997a, 1998a). In the assumptions, the author sets theory was changed to “human becoming” (Parse, forth the view that unitary humans, in mutual 1992). With process with the universe, are cocreating a unique the 1998 publication of The Human Becoming becoming. The mutual process is the all-at- School of Thought, Parse expanded the original onceness of living freely chosen meanings that arise work to include descriptions of three research with multidimensional experiences. The chosen methodologies and a unique practice methodology, meanings are the value priorities cocreated in tran- thus classifying the science of Human Becoming as scending with the possibles in unitary emergence a school of thought (Parse, 1997c). The principles and the assumptions of the human Human Becoming is a basic human science that becoming school of thought make up the ontology. The principles of human becoming, which describe the central phenomenon of nursing (the human- Human Becoming is a basic human science universe-health process), arise from the three that has cocreated human experiences as major themes of the assumptions: meaning, rhyth- its central focus. The ontology—that is, the assumptions and explicates fundamental paradoxes of human be- principles—sets forth beliefs that are clearly differ- coming (Parse, 1998a, p. Discipline-specific knowledge is articulated in Paradoxes are not opposites or problems to be unique language specifying a position on the phe- solved but, rather, are ways humans live their cho- nomenon of concern for each discipline. The principles are the author explicates the idea that humans con- referred to as the Human Becoming Theory. The struct personal realities with unique choosings concepts, with the paradoxes, describe the human- from multidimensional realms of the universe. This ontological base gives Reality, the meaning given to the situation, is the rise to the epistemology and methodologies of individual human’s ever-changing seamless sym- Human Becoming. Consistent with the Human Becoming symphony is the unique story of the human as mys- School of Thought, the focus of inquiry is on tery emerging with the explicit–tacit knowings of humanly lived experiences. The second principle (Parse, 1981, 1998a) de- Sciencing Human Becoming is the process of com- scribes the rhythmical patterns of relating human ing to know; it is an ongoing inquiry to discover with universe. Not all is explicitly methods; two are basic research methods and the known or can be told in the unfolding mystery of other is an applied research method (Parse, 1998a, human becoming. The methods ﬂow from the on- opportunities-restrictions present in all choosings tology of the school of thought. There are oppor- methods are the Parse Method (Parse, 1987, 1990, tunities and restrictions no matter what the choice. It is coming together two methods is to advance the science of Human and moving apart, and there is closeness in the sep- Becoming by studying lived experiences from par- aration and distance in the closeness. The phenomena for study changing; that is, moving beyond with the possibil- with the Parse Method are universal lived experi- ities, which are their intended hopes and dreams. Written texts from any lit- resist with powering in creating new ways of living erary source or any art form may be the subject of the conformity-nonconformity and certainty- research with the Human Becoming Hermeneutic uncertainty of originating, while shedding light on Method. The researcher in afﬁrming being in light of nonbeing” (Parse, 1998a, the Parse Method is truly present as the participant p. The being-nonbeing rhythm is all-at-once moves through an unstructured discussion about living the ever-changing now moment as it melts the lived experience under study. Humans, in originating, seek to the Human Becoming Hermeneutic Method is conform–not conform; that is, to be like others and truly present to the emerging possibilities in the unique all-at-once, while living the ambiguity of horizon of meaning arising in dialogue with texts the certainty-uncertainty embedded in all change. True presence is an intense attentive- The changing diversity arises with transforming the ness to unfolding essences and emergent meanings. The contributions of the ﬁndings from edge base underpinning true presence is speciﬁed studies using these two methods is “new knowledge in the assumptions and principles of human be- and understanding of humanly lived experiences” coming (Parse, 1981, 1992, 1995, 1997a, 1998a). Many studies have been con- True presence is a free-ﬂowing attentiveness that ducted and some have been published in which arises from the belief that the human in mutual nurse scholars used the Parse Method. Two studies process with the universe is unitary, freely chooses have been published in which the author used the in situations, structures personal meaning, lives Human Becoming Hermeneutic Method (Cody, paradoxical rhythms, and moves beyond with 1995c; Ortiz, 2003).
Readers are also advised to follow up source articles and any subsequent studies on the scoring system used on their unit identified above order 50mg azathioprine free shipping. Clinical scenario Joanna Tomlinson is 38 years old and was on holiday with her family when their hired car became involved in a tragic road traffic accident purchase azathioprine 50 mg without a prescription. She was sedated with a continuous intravenous infusion of midazolam (1 mg/ml) in order to facilitate ventilation and other treatments azathioprine 50 mg low cost. The midazolam infusion was administered at titrated rate of between 2 and 4 ml/h for 10 days. Evaluate any potentially longer-term effects and outline some nursing strategies which can minimise these. Chapter 7 Pain management Fundamental knowledge Nerve pathways—sympathetic, parasympathetic, motor, sensory Spinal nerves Stress response (see Chapter 3) Introduction Much literature on pain management focuses on pharmacology. Specific information on individual drugs (indications, contraindications, usual doses, preparation, benefits and adverse effects) can be found in the manufacturer’s data sheets and pharmacopaedias (e. British National Formulary), both of which should be available in all clinical areas. Individual nursing assessments may identify ways to minimise discomfort—information which should be shared with colleagues (verbally, nursing records). Pain should be controlled for humanitarian reasons, but pain also initiates all the detrimental physiological effects of stress response (see Chapter 3), while reluctance to breathe deeply (if self-ventilating) contributes to atelectasis (Puntillo & Weiss 1994). How the stimuli are perceived by the cerebral cortex determines whether pain exists and, if so, its type and intensity (‘quality’). Pain is therefore necessarily individual to each sufferer, a complex interaction between physiology and psychology. The individuality of pain experiences underlies McCaffery’s widely quoted definition: ‘pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does’ (McCaffery & Beebe 1994:15). However some patients may deny pain, even if experiencing it (possibly due to social expectations—‘stiff upper lip’). McCaffery and Beebe (1994) add that nurses should not accept denial of pain, but explore reasons for that denial. Sternbach (1968) described pain in terms of ‘hurt’ and ‘tissue damage’, but ‘hurt’ merely replaces one word by another without clarifying concepts. Pain as a signal of tissue damage (defence mechanism) also ignores psychological stressors, individual interpretations, or powerlessness to prevent tissue degeneration causing chronic pain (e. Nerve fibres Pain is sensed by nociceptors which exist throughout almost all body tissue, especially the skin. A fibres are large; their thick myelin sheaths enable rapid conduction—up to 20 m/s (Grubb 1998). A- delta fibres are found mainly in skin, skeletal muscle and joints, producing sharp and well-localised impulses and defensive motor reflex withdrawal (Melzack & Wall 1988). C fibres transmit dull, poorly localised, deep and prolonged pain signals, resulting in guarded movements and immobility. Sharp impulses from the fast A-delta fibres are superseded by slower, dull and prolonged impulses from C fibres. Pain may be described in these or other terms, and descriptions may indicate the sources of pain (e. Pain management 63 Gate control theory Ancient associations of pain with the heart bequeathed linguistic concepts and images (e. Descartes’ description of direct pain pathways to the brain, although now recognised as grossly oversimplistic, influenced many subsequent theories. While pain mechanisms remain unproven, Melzack and Wall’s ‘gate control’ theory is widely accepted. Hopes that neuropeptide endorphins (endogenous morphines) would achieve better pain control than exogenous narcotics have been disappointed (McCaffery & Beebe 1994). Psychology The perception of signals received is influenced by various psychological factors, including culture anticipation (past experience, fear, misinterpretation) distraction. The word ‘pain’ derives from the Latin poena (punishment) (Schofield 1994), and the perception of pain as retribution may be partly a psychological coping mechanism, but it also encourages stoic attitudes of endurance that can be physiologically harmful. Cultures can also influence whether, when and how it is acceptable to admit to pain. Distraction may help people cope with pain (Puntillo 1988) by blocking the gate with other impulses and stimulating serotonin release. Stereotypes While recognising cultural influences (especially when pain is denied), stereotyping people is unhelpful and dehumanising; the examples below illustrate some of the dangers. Men are expected to tolerate more pain than women (McCaffery & Beebe 1994), and so are less likely to report it (Puntillo & Weiss 1994), but in fact pain tolerance is similar between the genders (Phillips 1997). Pain management 65 Children used to receive little analgesia, even though pain pathways are intact by 30 weeks gestation (Tatman & Ralston 1997); misconceptions may still prevent children receiving adequate analgesia (see Table 7. Even if pain impulses were comparable, pain experiences are unique to each individual necessitating individual assessment, which should be a nursing priority (Doverty 1994). Assessing pain Pain assessment, together with nursing knowledge and attitudes, is fraught with problems. Compared with patients’ own assessments, nurses consistently underestimate pain (Seers 1987; Ferguson et al. Since it is impossible to judge what others are experiencing, it is better to give too much analgesia rather than too little (McCaffery & Beebe 1994). Verbal assessment may be influenced by a nurse’s choice of words and so ‘hurt’, ‘discomfort’, ‘ache’ and ‘soreness’ may identify discomforts that would be denied as ‘painful’ (McCaffery & Beebe 1994). Pharmacological interventions Although the actions of drugs are often complex, including significant psychological/placebo components, analgesics can be divided between those with peripheral actions (e. Observe for skeletal muscle response (a) body movement immobility purposeless or inaccurate body movements protective movements include withdrawal reflex rhythmic movements (b) facial expression: clenched teeth wrinkled forehead biting of lower lip widely opened or tightly shut eyes 2. Autonomic nervous system response (a) sympathetic nervous system activation: increased pulse increased respiration increased diastolic and systolic blood pressure cold perspiration pallor dilated pupils nausea muscle tension (b) parasympathetic activation in some visceral pain low blood pressure slow pulse 3. Verbal report of pain Pain management 67 Questions to elicit from the patient location of pain intensity of pain (scale 1–10) onset and duration precipatating and aggravating factors nature of pain (i. Questions nurses should ask themselves (a) How long has it been since the fresh postoperative patient was medicated for pain? Most peripheral analgesics are anti-inflammatory, making them effective against musculoskeletal pain. Since prostaglandin inhibition impairs platelet aggregation, coagulopathies may be aggravated. Intensive care nursing 68 Opiates Opiates bind to receptors in the central nervous system; three types of receptors have been identified: mu, kappa and sigma. Since fats and fat soluble molecules readily cross the blood- brain barrier, lipid soluble (lipophilic) analgesics act quickly. Differences between opiates are relatively small and so choice largely depends on the personal preference of prescribers/users (Bergman & Yate 1997). Continuous infusions can cause accumulation if drugs have prolonged action or if renal or hepatic metabolism is impaired (renal failure, hepatic failure). It suppresses impulses from C fibres, but not A-delta fibres, and so relieves dull, prolonged pain.
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