By E. Hamil. Warren Wilson College.

John Bowlby During the Second World War capoten 25 mg, Bowlby moved away 1907-1990 from child research and conducted studies on officer se- British psychiatrist who discovered insights into the lection criteria for the military discount capoten 25mg mastercard. In 1946 he joined the staff of the John Bowlby’s pioneering work on the relationship Tavistock Clinic in London cheap 25 mg capoten mastercard, where he spent the remain- between mothers and children was instrumental in shap- der of his career. During his years at Tavistock, Bowlby ing child psychology in the twentieth century. These types of mother), and his belief that early experience influenced disorders that could be termed disorders of the brain in a later behavior grew stronger. From 1950 to 1952, Bowl- broad sense include depression, schizophrenia, and by served as a consultant for the World Health Organiza- bipolar disorder. Beyond these, however, are several tion, in which he worked with orphaned and institution- other types of disorders of the brain, including stroke, alized children who had been separated by their mothers. The term; when physicians speak of strokes, they are refer- books included Attachment (1969), Separation (1973), ring to thromboses, hemorrhages, or embolisms. Initially, his theories were attacked by ly, the term stroke refers to the loss of blood to a part of traditional psychoanalysts (including Anna Freud) who the brain and the resulting tissue damage. But as variables involved, strokes are often not correctly diag- psychologists and psychiatrists revised Freud’s theories, nosed. Often, especially with very mild events, a patient they realized that Bowlby’s theories were both innova- will attribute odd sensations to something else. He continued his speaking, if tissue damage occurred in the right brain association with Tavistock, but he also spent more time hemisphere, the victim may experience some degree of at his vacation home on the Isle of Skye, off the Scottish paralysis on the left side of the body, a distortion of vi- coast, with his family. If the tissue affected is on of Charles Darwin,was published in 1990, only months the left side of the brain, patients may experience some before his death of a stroke on September 2 on Skye. Milite Other common brain disorders include the array of conditions caused by head trauma. Injuries to the head can, obviously, vary tremendously, but such injuries all Further Reading result in biochemical abnormalities in the brain. New York, the head has been injured in some way, a tremendous Basic Books, 1969, 1973, 1980. Lon- often have detrimental effects on brain cells, including don, Routledge, 1993. Recent medical advances have uncovered some drugs and treat- ments that can offset this after-effect of trauma, and physicians now know that brain cells can be replaced in Brain disorders adults, a procedure that was thought impossible only a decade ago. Doctors now have the ability to procure ac- Any of the various disorders associated with the curate images of the brain from magnetic resonance human brain, including stroke, trauma, and tu- mors. It has recently been reported that neurology, the The incidence of brain tumors has increased in re- study of the brain, is the fastest growing specialty in the cent years, although it is not certain if this trend is sim- life sciences. Nonetheless, treatments devised thus far have of the more prevalent brain disorders. Researchers have found varieties of brain disorders that affect humans, including that certain genes inside tumors are capable of creating Alzheimer’s disease, Parkinson’s disease, epilepsy, resistance to drugs being used to destroy the tumor. The four principal Developmental neurologic disorders of the brain in- sections of the human brain are the brain stem, the dien- clude well-known brain diseases such as Alzheimer’s, cephalon, the cerebrum, and the cerebellum. Most of these disorders are now known to be inheritable, passed from one generation to another genetically. Re- The brain stem cent research has isolated the gene that causes strains of The brain stem connects the brain with the spinal Alzheimer’s, Huntington’s disease, and several other cord. Cerebral palsy, a devastating devel- brain and spinal cord pass through the medulla—a part opmental neurologic disorder involving severe muscle of the brain stem—via fibers. The fibers on the right side and coordination deterioration, has been attributed to of the medulla cross to the left and those on the left cross stroke in newborn infants. The medulla also controls spent the following studying brain disorders: the heartbeat, the rate of breathing, and the diameter of Alzheimer’s disease, $305 million; stroke, $116 million; the blood vessels and helps to coordinate swallowing, multiple sclerosis, $80 million; Parkinson’s disease, $72 vomiting, hiccupping, coughing, and sneezing. Another million; epilepsy, $55 million; and head injury, $51 mil- component of the brain stem is the pons (meaning lion. Conveying impulses between the cerebral Further Reading cortex, the pons, and the spinal cord is a section of the “Cognitive Impairment to Dementia. The diencephalon The diencephalon lies above the brain stem and em- bodies the thalamus and hypothalamus. The thalamus Brain is an important relay station for sensory information, in- Part of the central nervous system located in the terpreting sensations of sound, smell, taste, pain, pres- skull. Controls mental and physical actions of the sure, temperature, and touch; the thalamus also regulates organism. The hypothalamus con- trols a number of body functions, such as heartbeat rate The brain, with the spinal cord and network of and digestion, and helps regulate the endocrine system nerves, controls information flow throughout the body, and normal body temperature. The hypothalamus inter- voluntary actions, such as walking, reading, and talking, prets hunger and thirst, and it helps regulate sleep, and involuntary reactions, such as breathing and heart- anger, and aggression.

Protocols for all clinical trials must be reviewed and approved by a properly constituted independent ethics committee generic 25 mg capoten with amex. This revealed that toxicology in clinical trials often have better health outcomes than those data demonstrating cataract formation in rats and dogs not involved in a trial generic capoten 25mg. Triparanol was withdrawn discount 25mg capoten with visa, but some of the patients who had been taking it for a year or longer also developed cataracts. Drug and therapeutics bulletin; from trial outcomes to clin- conferences on harmonization of requirements for registration ical practice. Section 1: Drug discovery hopefully without stifling research with excessive bureaucracy and development. Recent progress in molecular genetics, cell biology and aid the identification of orally bioavailable peptides. Nucleic the human genome has assisted the discovery of the mecha- acids for gene therapy (see below) are also inactive when nisms and potential therapies of disease. Drug delivery for such molecules is a nucleotide sequence that has a particular function (e. Since then, more permitted the synthesis of these human proteins in large than 100 medicines derived via biotechnology have been quantities, their only source was human tissues or body flu- licensed for use in patients, whilst hundreds more are cur- ids, carrying an inherent risk of viral (e. An example in which protein coagulation factors, enzymes and monoclonal antibodies, replacement is life-saving is the treatment of Gaucher’s dis- extending the range of useful therapeutic agents from low ease, a lysosomal storage disease, which is caused by an molecular weight chemical entities to macromolecules. Once inborn error of metabolism inherited as an autosomal reces- discovered, some biotechnology products are manufactured sive trait, which results in a deficiency of glucocerebrosidase, by chemical synthesis rather than by biological processes. In in the lysosomes of the reticulo-endothelial system, particu- parallel with these advances, the human genome project is larly the liver, bone marrow and spleen. This may result in establishing associations between specific genes and specific hepatosplenomegaly, anaemia and pathological fractures. Detailed medical histories and genetic information Originally, a modified form of the protein, namely alglucerase, are being collected and collated from large population sam- had to be extracted from human placental tissue. This will identify not only who is at risk of a potential dis- enzyme is now produced by recombinant technology. Likewise, the use of human recombinant growth the right drug for the individual patient – a ‘holy grail’ known hormone has eliminated the risk of Creutzfeldt–Jakob disease as personalized medicine. Achieving this grail is not immi- that was associated with human growth hormone extracted nent. It is not just the physical presence but, more importantly, from bulked cadaver-derived human pituitaries. Often a complex inter- Recombinant technology is used to provide deficient pro- action between many genes and the environment gives rise to teins (Table 16. Most facilitate the body’s immune sys- tem in destroying the cancer cells or reduce the blood supply Mode of action Indication to the tumour. It is a receptors murine monoclonal antibody and can only be used in an indi- Follitropin Recombinant human Infertility vidual patient once. Most recently developed monoclonal alfa and follicle stimulating antibodies have been fully humanized. In comparison to most beta hormone conventional ‘small molecule’ drugs, the antibodies’ activities Insulin aspart, Recombinant human Diabetes (helps are very specific and toxicity is usually directly related to the glulisine and insulin analogues, glucose control in targeted effect either through excessive effect or a ‘down- stream’ consequence of the effect. The effects are usually very lispro faster onset of action some patients/ species-specific, so extrapolation from animal studies is more situations) difficult. Immunoglobulins for specific epitopes of influenza virus may be developed, have been gradually humanized to reduce the risk of an manufactured and distributed much more rapidly and effec- immune response on repeated treatments. With the current likelihood of an influenza pandemic In cancer therapy, monoclonal antibodies have been devel- caused by a new strain of virus predicted by the World Health oped against a tumour-associated antigen, e. However, germ-line gene therapy is prohibited at present because of the unknown possible consequences and hazards, not only to the individual but also to future generations. Whereas gene therapy research was ini- The increasing potential to exploit advances in genetics and tially mainly directed at single-gene disorders, most of the biotechnology raises the possibility of prevention by gene research currently in progress is on malignant disease. Gene therapy both of some relatively common diseases which are therapy trials in cancer usually involve destruction of tumour currently reliant on symptomatic drug therapy, and of genetic cells by the insertion of a gene that causes protein expression disorders for which there is currently no satisfactory treat- that induces an immune response against those cells, or by the ment, let alone cure. It is caused by a apy may involve the deliberate modification of the genetic mutation in the cystic fibrosis transmembrane conductance material of either somatic or germ-line cells. Adenoviral vectors are more efficient Antigen than liposomes but themselves cause serious inflammatory Gold particle presenting Translated coated with cell to protein reactions. This probably presented to the immune reflects problems with the retrovirus vector. T cells from the original bone marrow donor can mediate response regression of the malignancy, but can then potentially damage Figure 16. This be eliminated after the tumours had regressed and so avoid intracellular foreign protein is then processed by proteasomes future damage to normal tissues. From the above, it will be appreciated that a major problem in gene therapy is introducing the gene into human cells. The other major problem is that for most dis- muscle cells or pancreatic insulin-producing cells, under eases it is not enough simply to replace a defective protein, it particular physiological conditions. Non-myeloblastic allogenic stem cell transplantation is These are nucleotides (approximately 20mers in length) being increasingly used, particularly in the elderly.

Whitney Cerak was alive and the Cerak family had unknowingly buried Laura Van Ryn after a closed-casket funeral that drew several thousand mourners order 25mg capoten overnight delivery. Personal belongings were strewn throughout the crash site and both girls had similar facial features discount capoten 25 mg mastercard, blonde hair capoten 25mg for sale, and similar body weight. Van Ryn family members were unable to recognize the person they thought was Laura and did not realize the mix-up until weeks after the crash. After the error became obvious, dental record comparisons confrmed the identities of both girls. The Van Ryn and Cerak families, including Whitney Cerak, corrobo- rated on a 2008 book chronicling the events and the effects those events had on the families. A body that remains immersed in fresh water can decompose rapidly, depending on the water temperature, and may preclude the recording of postmortem fngerprints. Of course, it is not pos- sible to record fngerprints from skeletonized decedents. For fngerprints to be a useful identifcation tool in a specifc case, the person in question must have antemortem fngerprints on fle. Postmortem fngerprints are collected whenever possible, but comparison depends on the existence of prior fngerprint records. Tese should be used with caution, however, and should never be the sole determinant in the identifcation process. For example, afer a fery motor vehicle fatality, determining that the vehicle is registered to the same person named on a driver’s license found at the scene can be a very valuable clue. Tere are, however, documented cases where such deaths have been staged for various fraudulent purposes. Afer the World Trade Center attacks in 2001, frefghters who perished were found to be wearing other frefghters’ turnout coats. Identifcation errors could have been made from attempting to make positive identifcations using personal efects alone. Scars may be from previous trauma or surgical intervention and can be further investi- gated by the pathologist. Tattoos, if sufciently unique, can be used as an identifer of an individual or may indicate that individual belonged to a particular group or gang. See Chapters 5 and 11 for information concern- ing tattoos and scars and for methods for better imaging this evidence. A swab from a close relative, stored blood, or material from the decedent’s hairbrush or toothbrush may provide adequate comparison material. By providing efcient, accurate, and cost-efective human identifcation, forensic dentists play important roles in death investigation. Aggripina the Younger, wife of Emperor Cassius and mother of future Emperor Nero, contracted for the killing of a perceived rival, Lollia Paulina. In his account Dio reported, “She did not recognize the woman’s head when it was brought to her; she opened the mouth with her own hand and inspected the teeth, which had certain peculiarities. Bringing closure to a tragic or unexpected event will ofen give some peace and closure to the immediate family members in their time of grief. Although confrmation of death may be terrible, it ultimately leads to the possibility of resolution of a difcult time for family members. Te cause and manner of death may be very important items of information for life insurance companies and to the decedent’s family. Increased benefts for accidental death or clauses precluding payment for deaths from suicide, acts of war, or engaging in dangerous activities ofen mean that these cases are decided in courts of law. In multiple fatality incidents, identifcation of decedents is ofen difcult and commingling of remains may occur. In these situations great care must be taken to correlate all body fragments to the appropriate decedent. Dental identifcation may provide an identifed fragment to which other unknown fragments can be compared. See Chapter 16 for additional information concerning the legal aspects of forensic dental identifcation. Te mechanism of this process involves comparing features of an unknown specimen to those of a known individual. An accurate and detailed evaluation of the postmortem specimen will aford the best possibility of successfully comparing that information to antemortem information. Attention to detail at the postmortem exami- nation precludes errors that can lead to nonidentifcation and the need to repeat steps to get an accurate postmortem record. By following a step-wise examination checklist that includes photography, dental radiography, and dental charting, a forensic odontologist or forensic dental team can create consistently accurate postmortem dental records.

Table 1 illustrates the variety of functions a forensic physician may be asked to undertake discount capoten 25 mg otc. Some clinical forensic medical practitio- ners may perform only some of these roles 25mg capoten visa, whereas others may play a more History and Development 3 extended role order capoten 25 mg on-line, depending on geographic location (in terms of country and state), local statute, and judicial systems. Forensic physicians must have a good knowl- edge of medical jurisprudence, which can be defined as the application of medi- cal science to the law within their own jurisdiction. The extent and range of the role of a forensic physician is variable; many may limit themselves to specific aspects of clinical forensic medicine, for example, sexual assault or child abuse. Currently, the role and scope of the specialty of clinical forensic medicine glo- bally are ill defined, unlike other well-established medical specialties, such as gastroenterology or cardiology. In many cases, doctors who are practicing clini- cal forensic medicine or medical jurisprudence may only take on these func- tions as subspecialties within their own general workload. Pediatricians, emergency medicine specialists, primary care physicians, psychiatrists, gyne- cologists, and genitourinary medicine specialists often have part-time roles as forensic physicians. The specific English terms forensic medicine and medical jurisprudence (also referred to as juridical medicine) date back to the early 19th century. In 1840, Thomas Stuart Traill (2), referring to the connection between medicine and legislation, stated that: “It is known in Germany, the country in which it took its rise, by the name of State Medicine, in Italy and France it is termed Legal Medicine; and with us [in the United Kingdom] it is usually denomi- nated Medical Jurisprudence or Forensic Medicine. There is much dispute regarding when medical expertise in the determination of legal issues was first used. Other historical examples of the link between medicine and the law can be found throughout the world. Amundsen and Ferngren (3) concluded that forensic medicine was used by Athenian courts and other public bodies and that the testimony of physi- cians in medical matters was given particular credence, although this use of physicians as expert witnesses was “loose and ill-defined” (4), as it was in the 4 Payne-James Roman courts. The interaction between medicine and the law in these periods is undoubted, but the specific role of forensic medicine, as interpreted by historical docu- ments, is open to dispute; the degree and extent of forensic medical input acknowledged rely on the historian undertaking the assessment. Traill (2) states that: “Medical Jurisprudence as a science cannot date farther back than the 16th century. However, the Constitutio Criminalis Carolina, the code of law published and proclaimed in 1553 in Germany by Emperor Charles V, is considered to have originated legal medicine as a specialty: expert medical testimony became a requirement rather than an option in cases of murder, wounding, poisoning, hanging, drown- ing, infanticide, and abortion (1). Medicolegal autopsies were well documented in parts of Italy and Germany five centuries before the use of such procedures by English coroners. Cassar (7), for example, describes the earliest recorded Mal- tese medicolegal report (1542): medical evidence established that the male partner was incapable of sexual intercourse, and this resulted in a marriage annulment. Beck (8) identifies Fortunatus Fidelis as the earliest writer on medi- cal jurisprudence, with his De Relationibus Medicorum being published in Palermo, Italy, in 1602. Subsequently, Paulus Zacchias wrote Quaestiones Medico-Legales, described by Beck as “his great work” between 1621 and 1635. Beck also refers to the Pandects of Valentini published in Germany in 1702, which he describes as “an extensive retrospect of the opinions and deci- sions of preceding writers on legal medicine. Late 18th Century Onward Beginning in the latter part of the 18th century, several books and trea- tises were published in English concerning forensic medicine and medical History and Development 5 jurisprudence. What is remarkable is that the issues addressed by many of the authors would not be out of place in a contemporary setting. It seems odd that many of these principles are restated today as though they are new. In 1783, William Hunter (9) published an essay entitled, On the Uncer- tainty of the Signs of Murder in the Case of Bastard Children; this may be the first true forensic medicine publication from England. John Gordon Smith writes in 1821 in the preface to his own book (10): “The earliest production in this country, professing to treat of Medical Jurisprudence generaliter, was an abstract from a foreign work, comprised in a very small space. Davis (11) refers to these and to Remarks on Medical Jurispru- dence by William Dease of Dublin, as well as the Treatise on Forensic Medi- cine or Medical Jurisprudence by O. Davis considers the latter two works of poor quality, stating that the: “First original and satis- factory work” was George Male’s Epitome of Juridical or Forensic Medicine, published in 1816 (second edition, 1821). Male was a physician at Birming- ham General Hospital and is often considered the father of English medical jurisprudence. John Gordon Smith (9) stated in The Principles of Forensic Medicine Systematically Arranged and Applied to British Practice (1821) that: “Forensic Medicine—Legal, Judiciary or Juridical Medicine—and Medical Jurisprudence are synonymous terms. Beck published the first American textbook 2 years later in 1823 and a third edition (London) had been published by 1829 (8). John Gordon Smith (9) wrote that “Every medical practitioner being liable to a subpoena, should make it his business to know the relations of physi- ological and pathological principles to the facts on which he is likely to be interrogated, and likewise the principal judiciary bearings of the case. The former of these are to be found in works on Forensic Medicine; the latter in those on Jurisprudence. Personal identity Real & apparent death Identity Sudden dath Age Survivorship Sex 8.

Fluid management of critically ill patients necessitates the careful evaluation of benefits against disadvantages of each buy 25 mg capoten mastercard, and this is the focus of this chapter cheap 25 mg capoten overnight delivery. Nursing observations and records can identify the likely causes of oedema to guide appropriate fluid management: compounding extravasation only prolongs hypovolaemia and pulmonary complications order 25mg capoten overnight delivery. Extravascular fluids create a counter osmotic pressure, aggravated by any extravasation/leak of low-weight ‘colloids’ from increased capillary permeability. Fluid balance in critical illness is complex, and so hypovolaemia necessitates careful fluid management. Webb (1997) identifies three options for treating hypotension: ■ crystalloids ■ colloids ■ inotropes Using inotropes before correcting hypovolaemia (‘dry drive’) causes unpredictable maldistribution of blood flow, tachycardia and increased oxygen demand (Webb 1997). Right ventricular stretching or displacement of the ventricular septum reduces left ventricular filling, which may limit fluid resuscitation (Robb 1997). A major factor in determining their effect is their molecular size (indicated by molecular weight, usually measured in daltons (Da) or kilodaltons (kDa); where ‘molecular weight’ is cited, this is a slightly different measurement, but approximates to daltons). Like any ‘normals’, exact figures vary between authors; as vascular permeability varies with pathologies (see Chapter 25), precise molecular weights are less important than ranges within which molecules are measured. Small molecules and water readily diffuse across cell membranes, providing intracellular hydration. Crystalloids provide total body hydration, but rapid extravasation (normal saline plasma half-life is 15 minutes (Tonnesen 1994)) makes them unsuitable for persistent hypovolaemia whether through external blood loss (e. Rapid infusion of large crystalloid volumes could cause pulmonary oedema (MacIntyre et al. Five per cent glucose (in water) is often used to replace lost body water, but should be avoided with raised intracranial pressure as anaerobic metabolism of glucose produces lactic acid and water increasing oedema (North & Reilly 1994). Crystalloid fluid is unsuitable for the replacement of large volumes of intravascular fluid, and so is not discussed further here. Intensive care nursing 326 Perfusion Tissue perfusion is needed to supply nutrients to cells and remove the waste products of metabolism. Capillary permeability varies greatly, ranging from the “blood-brain barrier (least permeable) to renal glomerular beds (most permeable). Glomerular beds may filter positively charged substances up to 70 kDa (Adam & Osborne 1997), although clearance rate reduces as molecular size increases; the plasma half-life of crystalloids (low molecular weight) is brief, and the half-life of low molecular weight colloids (e. Fluids with larger molecular structures remain intravascularly until metabolised into smaller molecules (which can be excreted). Thus the effects of intravascular fluids depend upon molecular size and metabolic rate. Colloids Colloids are fluids with large molecules (above 10 kDa according to Webb (1991)). People can survive an 80 per cent loss of erythrocytes, but only a 30 per cent loss of blood volume (Williamson 1994), and so blood is normally only given when there is significant loss of erythrocytes (packed cell volumes below 33 per cent or Hb below 10). Since donor blood is foreign protein, immunological reactions (both from cellular and plasma components) can occur; although these are usually limited to mild fever and slight hypotension, anaphylactic shock can occur. Reactions are normally minimised by crossmatching blood between recipient and donor, but emergency situations—where the risk from not giving blood exceeds the risk from the blood itself—may necessitate giving blood without crossmatching (Isbister 1997a). Although whole blood is sometimes used, blood is more often separated into components. Packed cells, fresh frozen plasma, platelets and albumin are the most commonly encountered blood products, although there are a wide range of other products (including various other clotting factors) available to treat specific needs. The increasing chemical instability of blood creates complications; expiry dates on each unit allow 40 days’ shelf life, but as instability is progressive, nurses should be watchful for potential complications, especially as the units near their expiry dates. The most commonly used preservative is citrate, which is metabolised via Krebs’ cycle. Citrate is acidic (Ali & Ferguson 1997); metabolism reduces plasma calcium (Isbister 1997a), potentially affecting muscle (including myocardial) contractility; thus large transfusions of blood may necessitate calcium supplements. A bag of approximately 500 ml whole blood contains 70 ml of preservative (Isbister 1997a), so that in addition to other complications, preservative causes mild haemodilution. Intensive care nursing 328 Cellular metabolism continues during storage (Ali & Ferguson 1997), and so storage time reflects increasing complications. Problems are accentuated with whole blood as leucocytes create an adverse storage environment for most blood components (Isbister 1997a). Intracellular concentrations of potassium and sodium reverse plasma levels, causing progressive hyperkalaemia in stored blood. Potassium levels should therefore be checked when patients receive blood; however, with cell recovery following transfusion, potassium returns to intracellular fluid, causing potential rebound hypokalaemia within 24 hours (Isbister 1997a). Up to one-third of cells may die during storage; metabolism of dead cells increases hepatic workload, potentially overwhelming hypofunctioning livers and causing jaundice. Blood is stored at 4°C to minimise metabolism; warming to 37°C consumes 1255 kJ (which is equal to one hour of muscular work, requiring 62 litres of oxygen) (Isbister 1997a); this extra workload may place significant strain on an already hypoxic patient. Blood and blood products should therefore be warmed at least to room temperature (20°C) before transfusion. Blood stored at room temperatures (or other inappropriate temperatures) should not be used, but returned to the haematology department.

This knowing occurs only • To have thorough or practical understanding of 25mg capoten overnight delivery, when the person allows the nurse to enter his or her as through experience of world buy cheap capoten 25 mg. In this occurrence generic capoten 25mg, the nurse and nursed • To be subjected to or limited by become vulnerable as they move toward further • To recognize the character or quality of continuous knowing. In such situations, Daniels (1998) explains that “nurse’s work is to ameliorate While the action word know sustains the notion vulnerability” (p. The embodiment of vulner- that nursing is concerned with activity and that the ability in caring situations enables its recognition in one who acts is knowledgeable (in the sense of un- others, participating in mutual vulnerability condi- derstanding the rationales behind the activities), tions, and sharing in the humanness of being vul- the word knowing is a key concept that alludes to nerable. Further, Daniels declares that “vulnerable the focus of an action from a cognitive perspective individuals seek nursing care, and nurses seek those requiring description. Allowing the nurse to dic dictionary attributes the definition of knowing enter the world of the one nursed is the mutual en- as an adjective. Described here are the four descrip- gagement of “power with” rather than having tions of knowing: “power over” through a created hierarchy (Daniels, • Possessing knowledge, intelligence, or under- 1998). The nurse does not know more about the standing person than the person knows about himself or • Suggestive of secret or private information herself. No one knows the experience better than • Having or showing clever awareness and the person who encounters the situation. When this occurs, these situations Yet, “knowing” perfectly describes the ways of forcibly lead nurses to appreciate persons more as nursing—transpiring continuously as explicated objects than as person. The frame- that with the process of “knowing persons as work for practice clearly shows the circuitous and whole,” opportunities to continuously know the continuous process of knowing persons as a prac- other become limitless, there is also a much greater tice of nursing. Using Empirical Nursing: technologies Personal Affirmation, competently to Ethical Support, appreciate persons Aesthetic Celebration of as whole in the who is person? Responses to Calls for Nursing: Sustaining and enhancing who is person and what is person? While it is appreciated that nurses practice nurs- allowed to understand and anticipate the ing from a theoretical perspective rather than from ever-changing person from moment to moment. Contrary to this popular conception, sons as ever-changing, never static, and “knowing persons” as a model of practice using who are dynamic human beings. Technologies allow nurses to The purpose of knowing the person is derived from know about the person only as much as what the the nurse’s intention to nurse (Purnell and Locsin, person permits the nurse to know. It can be true 2000)—a continuing appreciation of the person as that technologies detect the anatomical, physiolog- ever-changing, never static, and one who is a dy- ical, chemical, and/or biological conditions of a namic human being. This identifies the person as a living human knowing the person is only relevant for the mo- being. Importantly, views of human beings as persons convincingly knowing the “who or what” of persons helps nurses dictate the practice of nursing. Nevertheless, the realize that a person is more than simply the phys- process of knowing persons will prevail, for the iochemical and anatomical being. Knowing per- model of technological competency as caring in sons allows the nurse to know “who and what” is nursing provides the nurse the fitting stimulation the person. From such a view, it may be a perception that the The model articulates continuous knowing. This perception is supported by the idea that nurs- Continuing to know persons deters objecti- ing is technology when technology is appreciated as fication of persons, thus inhibiting the anything that creates efficiency, be this an instru- process that ultimately regards human ment or a tool, such as machines, or the activity of beings as “stuff” to care about. Sandelowski (1993) has ar- persons are knowledgeable participants gued about the metaphorical depiction of nursing of their care. Regardless, the idea of knowing persons guiding a process that ultimately regards human beings as nursing practice is novel in the sense that there is “stuff” to care about, rather than as knowledgeable no prescription or direction that is the ideal; rather participants of their care. Participating in his or her there is the wholesome appreciation of an in- care frees the person from having to be “assigned” a formed practice that allows the use of multiple care that he or she may not want or need. This re- ways of knowing such as described by Phenix lationship signifies responsiveness (Hudson, 1988). These ways Continuous knowing results from the contention of knowing involve the empirical, ethical, personal, that findings or information appreciated through and aesthetic. Aesthetic expressions document, consequent knowing further informs the desire to communicate, and perpetuate the appreciation of know “who is” and “what is” the person. Continuous knowing overpowers the mo- poetry, visual expressions as in drawings, illustra- tivation to prescribe and direct the person’s life. Encountering aes- her hopes, dreams, and aspirations as a participat- thetic expressions again allows the nurse and the ing human being. Calls for nursing sional practice grounded in a legitimate theoretical are individual expressions by persons who seek perspective of nursing. The nurse appreciates the uniqueness of to the contemporary demands for nursing actions persons in his or her nursing. There is no let- sustains and enhances the wholeness of the human ting up, because advancing technology currently being, while facilitating the realization of the per- encompasses the bulk of functional activities that sons’ completeness through “acting for or with” the nurses are expected to perform, particularly when person. These calls are specific mechanisms that persons use while allowing the nurse to respond with authentic intentions to know them fully as persons in the moment. Calls for nursing may be The purpose of this chapter is to describe and expressed in various ways, oftentimes as hopes and explain “knowing persons as whole,” a frame- dreams, such as hoping to be with friends while re- work of nursing guiding a practice grounded cuperating in the hospital, or desiring to play the in the theoretical construct of technological piano when his or her fingers are well enough to competency as caring in nursing (Locsin, function effectively, or simply the ultimate desire to 2004). As uniquely nates the harmonious relationship between as these calls for nursing are expressed, the nurse technology competency and caring in nurs- knows the person continuously moment to mo- ing.

The symptoms of Asperger‘s are almost identical to that of autism (with the exception of a delay in language development) purchase 25 mg capoten amex, and the child psychiatrist simply saw these problems as less extreme generic capoten 25 mg without a prescription. Clearly there is something wrong with their child buy 25mg capoten with mastercard, but even the experts cannot agree on exactly what the problem is. Diagnosing problems such as Jared‘s is difficult, yet the number of children like him is increasing dramatically. Disorders related to autism and Asperger‘s disorder now affect almost 1% of [25] American children (Kogan et al. The milder forms of autism, and particularly Asperger‘s, have accounted for most of this increase in diagnosis. Although for many years autism was thought to be primarily a socially determined disorder, in which parents who were cold, distant, and rejecting created the problem, current research suggests that biological factors are most important. The heritability of autism has been estimated [26] to be as high as 90% (Freitag, 2007). Scientists speculate that autism is caused by an unknown genetically determined brain abnormality that occurs early in development. It is likely [27] that several different brain sites are affected (Moldin, 2003), and the search for these areas is being conducted in many scientific laboratories. The problem is that diagnosis is not exact (remember the idea of “categories‖), and the experts themselves are often unsure how to classify behavior. Can you think of or find clips from any films or other popular media that portray mental illness positively or negatively? Is it more or less acceptable to stereotype the mentally ill than to stereotype other social groups? Generalized anxiety disorder and major depressive disorder comorbidity in the National Survey of Mental Health and Well Being. Presented to the Standing Senate Committee on Social Affairs, Science and Technology. Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed. Exposures to environmental toxicants and attention- deficit/hyperactivity disorder in U. Maternal lifestyle factors in pregnancy risk of attention- deficit/hyperactivity disorder and associated behaviors: Review of the current evidence. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: A randomised, double-blinded, placebo- controlled trial. Sources of covariation among attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder: The importance of shared environment. The genetics of autistic disorders and its clinical relevance: A review of the literature. Explain the biological and environmental causes of anxiety and dissociative disorders. Anxiety, the nervousness or agitation that we sometimes experience, often about something that is going to happen, is a natural part of life. We all feel anxious at times, maybe when we think about our upcoming visit to the dentist or the presentation we have to give to our class next week. Anxiety is an important and useful human emotion; it is associated with the activation of the sympathetic nervous system and the physiological and behavioral responses that help protect us from danger. But too much anxiety can be debilitating, and every year millions of people suffer from anxiety disorders, which arepsychological disturbances marked by irrational fears, [1] often of everyday objects and situations (Kessler, Chiu, Demler, & Walters, 2005). Generalized Anxiety Disorder Consider the following, in which “Chase‖ describes her feelings of a persistent and exaggerated sense of anxiety, even when there is little or nothing in her life to provoke it: Attributed to Charles Stangor Saylor. The best way to describe it is like a really bad feeling of negative inevitability, like something really bad is impending, but I don’t know what. It’s like I’m on trial for murder or I’m just waiting to be sent down for something. I have it all of the time but it gets worse in waves that come from nowhere with no apparent triggers. I used to get it before going out for nights out with friends, and it kinda stopped me from doing it as I’d rather not go out and stress about the feeling, but now I have it [2] all the time so it doesn’t really make a difference anymore. The sufferer cannot deal with what is causing the anxiety, nor avoid it, because there is no clear cause for anxiety. In fact, the sufferer frequently knows, at least cognitively, that there is really nothing to worry about. Generalized anxiety disorder is most likely to develop between the ages of 7 and 40 years, but its influence may in some cases lessen with [4] age (Rubio & Lopez-Ibor, 2007). I was driving home, my three little girls were in their car seats in the back, and all of a sudden I couldn‘t breathe, I broke out into a sweat, and my heart began racing and literally beating against my ribs! Symptoms of a panic attack include shortness of breath, heart palpitations, trembling, dizziness, choking sensations, nausea, and an intense feeling of dread or impending doom. Panic attacks can often be mistaken for heart attacks or other serious physical illnesses, and they may lead the person experiencing them to go to a hospital emergency room.