By W. Daryl. Soka University of America.

Within our community who was on her treatment team remarked order flavoxate 200 mg otc, “We of nurses it became clear that developing individual weren’t listening to what she was telling us—we voices was our first task purchase flavoxate 200 mg fast delivery. She to become more articulate and clear about function noted with some surprise that her initial impres- and value as nurses order flavoxate pills in toronto. The theme of developing an sion that a patient she was working with was hostile articulate voice has pervaded and continues to and withholding had given way to the realization pervade this group. There is an ever-increasing that this patient—as a result of the negative symp- awareness of both manner and language as we in- toms of schizophrenia—was quite empty and was teract with one another and those outside the really giving us all that she had to give. The resolve for an articulate voice is even interactions with this patient, the nurse was em- more firm as members of the group experience and pathic and supportive rather than judgmental and share the empowering effect it can have on both angry. It has been said that “those that express themselves unfold in health, beauty, and human potential. Another group experience in which Humanistic Group members offered alternative approaches Nursing Theory was utilized was the formation of a to various situations that were utilized and subse- community of nurses who were mutually strug- quently brought back to the group. Zderad proposed, “each person might be practice is: Is this particular intersubjective- viewed as a community of the beings with whom transactional nursing event humanizing or she has meaningfully related” (1978, p. Nurses as clinicians, teachers, a potential resource for expanding herself as a researchers, and administrators can use the “knowing place. Through this under- could truly appreciate the unique competence of standing we are given direction for expand- one another, they were able to reflect that apprecia- ing ourselves as “knowing places” so that we tion back. Through this reflection, members began can fulfill our reason for being, which, ac- to internalize and then project a competent image cording to Humanistic Nursing Theory, is of themselves. They learned that this positive mir- nurturing the well-being and more-being of roring did not have to come from outsiders. This reciprocity is a self-enhancing process, for “the degree to which References I can create relationships which facilitate the Barnum, B. Nursing theory: Analysis, application, growth of others as separate persons is a measure of evaluation. Conduct your own awareness ses- strive to do this for one another and the profession sions: 100 ways to enhance self-concept in the classroom. Paper sounded in and exemplified by the following presented at the Syracuse Veteran’s Administration Hospital, description of examining a pregnant woman: New York. Perceiving, behaving, and becoming: 100 the information [on her and her fetus] from ways to enhance self-concept in the classroom. Secretary’s com- from humanity to maintain the humanness mission on nursing, final report. New creasingly concerned with cost containment, York: National League for Nursing. Orem Introducing the Theorist Views of Human Beings Specific to Nursing Summary References Introducing the Theorist She argues that nursing is distinguished from other human services and other forms of care by the way Dorothea E. In the 1950s, development of distinctive nursing knowledge she had the foresight to recognize the need to iden- (Fawcett, 2000, p. Orem contends that the tify the proper focus of nursing and to clarify the term “care”describes nursing in a most general way, domain and boundaries of nursing as a field of but does not describe nursing in a way that distin- practice in order to enhance nursing’s disciplinary guishes it from other forms of care (Orem, 1985). She began her work by seeking an an- swer to the question of what conditions exist in people when judgments are made about their need Nursing is distinguished from other human for nursing care. She concluded that the human services and other forms of care by the condition associated with the need for nursing is way in which it focuses on human beings. This in- of a nursing system demonstrates the foregoing sight provided Orem with an answer to the ques- statements (Table 12–1). But it is not true that one can study and think about nursing without incorporating into one’s thought processes nursing-specific views of Views of Human Beings human beings. The integration of views of hu- Specific to Nursing mankind within views of nursing is the focus of this discussion. In this nonspecific generalization, the term “human health service” expresses what nursing is. The powers and properties of human beings The term implies that there are two categories of specific to nursing are named in the Nursing human beings: those who need the nursing service Development Conference Group’s general concept and those who produce it. They plies that nursing is a helpful activity, and the word are further developed in Orem’s 1995 work and in “health” indicates that the thrust of the service is earlier expressions of the Self-Care Deficit Nursing the structural and functional integrity of persons Theory, with its constituent theories of self-care, served. Without ques- general nursing concept or theory, gives names and tion it is individual human beings, through the roles to the two categories of human beings, attrib- activation of their powers for result-seeking and utes distinct human powers and properties to each, result-producing endeavors, who generate the identifies the interactions among them, and speci- processes and systems of care named “nursing. The Nursing Development tend and deepen knowing of both the structure Conference Group’s 1971 general conceptual model of the nursing processes and of the internal struc- Table 12–1 Concepts of Nursing and Nursing Systems A nursing system, like other systems for the provision of personal services, is the product of a series of relations be- tween persons who belong to different sets (classes), the set A and the set B. From a nursing perspective any mem- ber of the set A (legitimate patient) presents evidence descriptive of the complex subsets self-care agency and therapeutic self-care demand and the condition that in A demand exceeds agency due to health or health-related causes. Any member of the set B (legitimate nurse) presents evidence descriptive of the complex subset nursing agency which includes valuation of the legitimate relations between self as nurse and instances where, in A, certain values of the component phenomena of self-care agency and therapeutic self-care demand prevail. B’s perceptions of the conditionality of A’s subset objective therapeutic self-care demand on the subset self-care agency establishes the conditionality of changes in the states of A’s two subsets on the state of and changes in the state of B’s subset nursing agency. The activation of the components of the subset nursing agency (change in state) by B to deliberately control or alter the state of one or both of A’s subsets—therapeutic self-care demand and self-care agency— is nursing. The perceived relations among the parts of the three subsets (actual system) constitute the organization. The “mapping” of the behaviors in “mathematical or behavioral terms” provides a record of the system. Orem’s Self-Care Deficit Nursing Theory 143 ture, constitution, and nature of the powers and not done for self and dependents, including the properties of individuals who require nursing rationales for what is done or what is not done. Harré (1970) iden- Both kinds of care are time-specific entities pro- tifies a theory as a “statement-picture” complex that duced by individuals. The Nursing Development Conference they are identified in Self-Care Deficit Nursing Group’s 1971 Theory of Nursing System and the Theory as “patient variables” dealt with by nurses general theory of nursing (the Self-Care Deficit and persons in need of nursing care within the Nursing Theory) express both the nature of the en- processes through which nursing is produced. As tities and the interactions of the entities responsible the values of each vary, the relationship between for the processes, the patterns of behavior, known them varies. Both theoretical expressions had their associated reasons, individuals’ self-care agency is beginning in understandings of their formulators unequal in its development or operability for meet- about the reasons why individuals need and can ing their existent and changing therapeutic self- be helped through nursing. The real or potential existence of such a health- It is posited that in valid general theories of nurs- related deficit relationship between the care demand ing, the named nursing-specific conceptualizations and power of agency is the reason why individuals are the human points of reference that reveal the require nursing care. For example, in Self-Care planation that both internal and external condi- Deficit Nursing Theory, individuals throughout tions arising from or associated with health states their life cycles are viewed as having a continuing of individuals can bring about action limitation of demand for engagement in self-care and in care of individuals to engage in care of self (for example, self; the constituent action components of the de- lack of knowledge or developed skills, or lack of en- mand together are named the “therapeutic self-care ergy) (Orem, 1995). Individuals also are viewed as having erational powers of self-care agency and the kinds the human power (named “self-care agency”) to de- and frequencies of deliberate actions to be per- velop and exercise capabilities necessary for them to formed to know and meet individuals’ therapeutic know and meet the components of their therapeu- self-care demands in time and place frames of tic self-care demands. This human power with its place frames of reference (that is, their self-care constituent capabilities and disposition is named agency), are not adequate because of health state or “nursing agency. The identification and development of the components of their own therapeutic self-care de- power of nurses to design and produce nursing care mands and the therapeutic self-care demands of for others are essential elements in any valid general their dependents.

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This helps to avoid discomfort as well as irritation purchase generic flavoxate line, which can injure intes- tinal mucosa generic 200 mg flavoxate fast delivery. Lubricate the forefinger generously to reduce irritation of the rectum and insert the finger gently into the anal canal cheap flavoxate american express. The presence of the finger added to the mass tends to cause discomfort for the patient if the work is not done slowly and gently. Have a second person assist with the proce- dure to reassure and comfort the patient while the first person breaks up the mass. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Indicate the type of stool that figures below by writing your answers on the would be expected with each ostomy. Sigmoidoscopy hollow body organ using a long flexible tube containing glass fibers that transmit e. Lower gastrointestinal examination of an image that can be viewed Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. The visual examination of the lining of Match the term in Part A with its definition the distal sigmoid colon, the rectum, and listed in Part B. Barium sulfate is instilled into the large intestine through a rectal tube inserted b. The patient drinks barium sulfate, which coats the esophagus, stomach, and small j. The passage of excessively liquid and tion to test for pH or blood in the stool unformed stools Match the type of enema in Part A with its use 17. Used to lubricate the stool and intestinal listed in Part A with the illustration in Part B. Esophagus rectum and provide relief from gaseous distention Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Give an example of how the following factors might affect a patient’s bowel elimination. Developmental considerations: patient complaining of painful defecation due to hard, dry stools. Activity and muscle tone: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Develop a list of preferred foods to ensure healthy bowel elimination for the following patients. Describe the following exercises designed for his job complains of frequent diarrhea. Abdominal settings: What other factors are likely to promote healthy bowel elimination in these patients? Perform a physical assessment and write a nursing diagnosis for a patient who has just had a colostomy performed. List four reasons for prescribing cleansing will this patient face in his life, and what can enemas. Ileostomy: Use the following expanded scenario from Chapter 38 in your textbook to answer the questions below. Colostomy: Scenario: Leroy Cobbs, age 56, was recently diagnosed with prostate cancer. Describe how the following factors help pro- acetaminophen (Tylenol) with codeine for mote healthy bowel habits in patients. Cobbs reports that he had regular, pain-free bowel movements, once daily, before taking the pain c. He appears frustrated and says, “I’ll take my chances with the cancer pain in the future rather than take more pain d. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Reluctant to suggest substituting another medication too quickly, she asks more questions and Ms. What would be a successful outcome for in the morning and maybe a glass of wine at Mr. What intellectual, technical, interpersonal, is a workaholic computer programmer and and/or ethical/legal competencies are most spends what little spare time she has watching likely to bring about the desired outcome? She reports tiring after walking one flight of stairs and says she avoids all forms of vigor- ous exercise. Identify pertinent patient data by placing a single underline beneath the objective data in the case study and a double underline beneath 4. Complete the Nursing Process Worksheet on page 261 to develop a three-part diagnostic statement and related plan of care for this patient. Read the following patient care study and use your nursing process skills to answer the Patient strengths: questions below. Elgaresta, age 54, a single Hispanic woman, is being followed by a cardi- ologist who monitors her arrhythmia. At this visit, she says to the nurse practi- tioner who works with the cardiologist: “Right after I started taking that medication, I got 4. Pretend that you are performing a nursing terribly constipated, and nothing seems to assessment of this patient after the plan of help. The nurse practitioner realizes that Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. For the purposes of this exercise, develop the one patient goal that demonstrates a direct resolution of the patient problem identified in the nursing diagnosis. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Dullness bronchioles that are the sites of gas exchange are known as which of the following? A patient who has difficulty breathing, increased respiratory and pulse rates, and d. A nurse suctioning a patient through a is generally preferred, despite its addictive tracheostomy tube should be careful not to quality? Cough syrup with codeine catheter because it would cause which of the following to occur? Suctioning of carbon dioxide ing should be placed in which of the follow- ing positions?

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On the other hand order flavoxate with visa, it is now generally accepted that postpubertal females can experience penile vaginal penetration without sustaining any hymenal deficits; this is attributed to hymenal elasticity (142 buy flavoxate cheap online,143) buy flavoxate master card. Furthermore, the similarity between the dimensions of the hymenal opening among sexually active and nonsexually active postpubertal females (96) makes it impossible for the physician to state categorically that a person has ever had prior sexual intercourse unless there is other supportive evidence (pregnancy, spermato- zoa on a high vaginal swab; see Subheading 8. Vagina Lacerations and ruptures (full-thickness lacerations) of the vagina have been described in the medical literature after consensual sexual acts (145– 147). They are most commonly located in the right fornix or extending across the posterior fornix; this configuration is attributed to the normal vaginal asymmetry whereby the cervix lies toward the left fornix, causing the penis to enter the right fornix during vaginal penetration (147). Factors that pre- dispose to such injuries include previous vaginal surgery, pregnancy, and the puerperium, postmenopause, intoxication of the female, first act of sexual intercourse, and congenital genital abnormalities (e. Although most vaginal lacerations are associated with penile penetration, they have also been documented after brachiovaginal intercourse (“fisting”) (147), vaginal instrumentation during the process of a medical assessment (147), and the use of plastic tampon inserters (148). Vaginal lacerations have been documented without any direct intravagi- nal trauma after a fall or a sudden increase of intra-abdominal pressure (e. Injuries of the vagina have been noted during the examinations of com- plainants of sexual assault. These were described as “tears” (n = 10), bruises (n = 12), and abrasions (n = 4). Other articles that considered only macroscopically detect- able lesions found vaginal “injuries” in 2–16% of complainants of noncon- sensual penile vaginal penetration (133,134). However, one study included “redness” as a vaginal injury when, in fact, this is a nonspecific finding with numerous causes. Sexual Assualt Examination 97 When a vaginal laceration may have been caused by an object that has the potential to fragment or splinter, a careful search should be made for for- eign bodies in the wound (145) (this may necessitate a general anesthetic), and X-rays should be taken of the pelvis (anteroposterior and lateral), includ- ing the vagina, to help localize foreign particles (149). Any retrieved foreign bodies should be appropriately packaged and submitted for forensic analysis. Cervix Bruises and lacerations of the cervix have been described as infrequent findings after nonconsensual sexual acts (90,150,151). In one article, the inju- ries related to penetration by a digit and by a “knife-like” object. However, the areas of increased vascularity may have been normal variants (90), and the precise location of the other findings was not described. The more significant conditions noted were three microulcerations, two bruises, five abra- sions, and one mucosal tear. The incidence of these conditions was highest when the inspections followed intercourse in the previous 24 hours or tampon use. Although the specifics of the medicolegal assessment of the male genitalia are case dependent, the principles of the examination, whether of the com- plainant or the defendant, are the same. Penile Size Forensic practitioners may be asked to provide evidence on the size of a defendant’s penis in the flaccid state to support a hypothesis that a certain sexual act could not have occurred because of intergenital disproportion between the complainant and the defendant. However, such measurements are unhelpful because it is not possible to predict the maximum erectile size from the flaccid length, and there is “no statistical support for the ‘phallic fallacy’ that the larger penis increases in size with full erection to a significantly greater degree than does the smaller penis” (153). Furthermore, even when the erect penis is mea- sured during automanipulation or active coition, the measurements are recog- nized to be unreliable (153). Erections Forensic practitioners may also be asked to comment on a person’s abil- ity to achieve a penile erection, particularly if the male is young or elderly. Masters and Johnson (153) note that during their research, “penile erection has been observed in males of all ages ranging from baby boys immediately after delivery to men in their late eighties;” they report that one 89-year-old study subject was able to achieve a full penile erection and ejaculate. There- fore, it is not possible to reach a conclusion regarding erectile efficiency based on age alone. When a defendant reports erectile dysfunction, the expert opin- ion of a urologist should be sought. Penile erection may result from visual stimulation (including fantasy) or tactile stimulation. The penis, scrotum, and rectum are all sensitive to tactile stimulation (153), which may explain why involuntary penile erections can be experienced by a male subjected to nonconsensual anal intercourse. Semen Production Semen is not produced until the male experiences puberty, which usu- ally begins between 9 and 14 years of age (154). The normal volume of a single ejaculate is between 2 and 7 mL, and it will contain approx 50–120 million spermatozoa/mL. There are numerous congenital and acquired causes for impaired spermatogenesis (155), resulting in either decreased numbers (oligozoospermia) or absence of (azoospermia) spermatozoa. Both condi- tions may be permanent or transitory depending on the underlying cause. It is not possible to determine whether spermatozoa are present in the ejaculate without microscopic assessment. However, analy- sis of a defendant’s semen is not a routine part of the forensic assessment. Forensic Evidence After an allegation of fellatio, swabs from the complainant’s penis can be examined for saliva, but, as discussed earlier in Subheading 7. When an allegation of vaginal or anal intercourse is made, penile swabs from the sus- pect can be examined for cells, feces, hairs, fibers, blood, and lubricants. Swabs taken from the meatus and urethra are not suitable for microscopic assess- ment because some male urethral cells can be similar to vaginal cells (7). Therefore, when vaginal intercourse is alleged, two swabs (the first wet, the second dry) should be obtained sequentially from the coronal sulcus, and two additional swabs (the first wet, the second dry) should be taken sequentially from the glans and the shaft together. The swabs must be labeled accord- ingly, and the order in which the samples were obtained must be relayed to the scientist. The same samples are also taken if it is believed that a lubricant or condom has been used during a sexual act or if the assault involved fellatio or anal intercourse. Microscopic and Biochemical Analyses Such analyses of the penile swabs may be undertaken to identify cellular material, blood, or amylase. When the complaint is of anal intercourse, swabs that are discolored by fecal material can be analyzed for urobilinogen and examined microscopically for vegetable matter. Blood and feces have been recovered from penile swabs taken 15 and 18 hours, respectively, after the incident (for saliva, see Subheading 7. Medical Evidence When obtaining the relevant forensic samples, the forensic practitioner should inspect the male genitalia with particular reference to the following points: 1. Pubic hair should be described in terms of its coarseness, distribution (Tanner stages 1–5), and color. A note should be made if the pubic hair appears to have been plucked (including bleeding hair follicles), shaved, cut, or dyed. Acquired abnormalities, such as circumcision, Peyronie’s disease, balanitis xerotica obliterans, vasectomy scars, phimosis, tattoos, and piercing. Foreign bodies may be worn around the base of the penis, sometimes also encir- cling the scrotum, in an attempt to increase and sustain penile tumescence.

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