睿学教育Wisdome Education

David William Butterly, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/david-william-butterly-md

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The subthalamus is located below the thalamus and regulates the muscles of emotional expression erectile dysfunction shake drink buy viagra soft 100 mg with amex. The hypothalamus contains the centers for sexual reflexes; body temperature; water erectile dysfunction at the age of 20 viagra soft 50 mg on line, carbohydrate zocor impotence purchase viagra soft 100 mg on-line, and fat metabolism; and emotions that affect the heartbeat and blood pressure. It also has the optic chiasm (connecting the optic nerves to the optic tract), the posterior lobe of the pituitary gland, and a funnel-shaped region called the infundibulum that forms the stalk of the pituitary gland. A thin outer layer of gray matter called the cerebral cortex features folds or convolutions called gyri; furrows and grooves are referred to as sulci, and deeper grooves are called fissures. Each hemi- sphere has a set of controls for sensory and motor activities of the body. Interestingly, it’s not just right-side/left-side controls that are reversed in the cerebrum; the upper areas of the cerebral cortex control the lower body activities while the lower areas of the cortex control upper-body activities in a reversal called “little man upside down. The corpus callosum Chapter 15: Feeling Jumpy: The Nervous System 247 physically unites the two hemispheres and is the largest and densest mass of commis- sural fibers. Different functional areas of the cerebral cortex are divided into lobes: Frontal lobe: The seat of intelligence, memory, and idea association Parietal lobe: Functions in the sensations of temperature, touch, and sense of position and movement as well as the perception of size, shape, and weight Temporal lobe: Is responsible for perception and correlation of acoustical stimuli Occipital lobe: Handles visual perception Medulla The medulla, the region interior to the cortex, is composed of white matter that con- sists of three groups of fibers. Projection fibers carry impulses afferently from the brain stem to the cortex and efferently from the cortex to the lower parts of the central nerv- ous system. Association fibers originate in the cortical cells and carry impulses to the other areas of the cortex on the same hemisphere. Ventricles The brain’s four ventricles are cavities and canals filled with cerebrospinal fluid. The lateral ventricles com- municate with the third ventricle through the foramen of Monro. The third ventricle is connected by the cerebral aqueduct to the fourth ventricle, which is continuous with the central canal of the spinal cord and contains openings to the meninges. The fourth ventricle has openings that allow fluid to enter into the subarachnoid spaces. Lining the ventricles is a thin layer of epithelial cells known as ependyma, or the ependymal layer. Along with a network of capillaries from the pia mater, the ependyma and capillaries form the choroid plexus, which is the source of cerebrospinal fluid. The choroid plexus of each lateral ventricle produces the greatest amount of fluid. Fluid formed by the choroid plexus filters out by osmosis (refer to Chapter 2) and circulates through the ventricles. Fluid is returned to the blood through the arachnoid villi, finger-like projections of the arachnoid meninx, which absorbs the fluid. Twelve pairs of cranial nerves connect to the central nervous system via the brain (as opposed to the 31 pairs that connect via the spinal cord). Check out Table 15-1 for a listing of all the nerves, and then read on for a memory tool. That’s a mouthful, but students have come up with a number of memory tools to remember them. Our favorite is: Old Opera Organs Trill Terrific Arias For Various Grand Victories About History. Unmyelinated fibers, cell bodies, and neuroglia Part V: Mission Control: All Systems Go 250 44. The part of the brain that contains the thalamus, pituitary gland, and the optic chiasm is the a. Use the terms that follow to identify the parts of the brain shown in Figure 15-3. Fourth ventricle Chapter 15: Feeling Jumpy: The Nervous System 251 51 _____ 62 _____ 52 _____ 53 _____ 54 _____ 55 _____ 61 _____ 56 _____ 57 _____ 60 _____ Figure 15-3: Sagittal 59 _____ 58 _____ view of the brain. Wolters Kluwer Health — Lippincott Williams &Wilkins Taking Side Streets: The Peripheral Nervous System The peripheral nervous system is the network that carries information to and from the spinal cord. Among its key structures are 31 pairs of spinal nerves (see Figure 15-4), each originating in a segment of the spinal cord called a neuromere. Eight of the spinal nerve pairs are cervical (having to do with the neck), 12 are thoracic (relating to the chest, or thorax), five are lumbar (between the lowest ribs and the pelvis), five are sacral (the posterior section of the pelvis), and one is coccygeal (relating to the tail- bone). Spinal nerves connect with the spinal cord by two bundles of nerve fibers, or roots. The dorsal root contains afferent fibers that carry sensory information from receptors to the central nervous system.

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Smoking goal of erectile dysfunction treatment viagra soft 50 mg buy mastercard, alcohol use impotence in young males order viagra soft with amex, and illicit drug use reported by adolescents aged 12–17 years: United States erectile dysfunction due to old age 100 mg viagra soft amex, 1999–2004. Physical activity, fitness and fatness: Relations to mortality, morbidity and disease risk factors. Inverse association between physical inactivity and mental health in men and women. Preventive Medicine: An International Journal Devoted to Practice and Theory, 30(1), 17–25. The joint association of average volume of alcohol and binge drinking with hazardous driving behaviour and traffic crashes. Prevalence and the factors associated with binge drinking, alcohol abuse, and alcohol dependence: A population-based study of Chinese adults in Hong Kong. A World Health Organization perspective on alcohol and illicit drug use and health. The relationship between recent alcohol use and sexual behaviors: Gender differences among sexually transmitted disease clinic patients. Affect is guided by arousal—our experiences of the bodily responses created by the sympathetic division of the autonomic nervous system. Emotions are the mental and physiological feeling states that direct our attention and guide our behavior. The most fundamental emotions, known as the basic emotions, are those of anger, disgust, fear, happiness, sadness, and surprise. A variety of secondary emotions are determined by the process of cognitive appraisal. The distinction between the primary and the secondary emotions is paralleled by two brain pathways: a fast pathway and a slow pathway. The Cannon- Bard theory of emotion proposed that the experience of an emotion is accompanied by physiological arousal. The James-Lange theory of emotion proposes that our experience of an emotion is the result of the arousal that we experience. The two-factor theory of emotion asserts that the experience of emotion is determined by the intensity of the arousal we are experiencing, but that the cognitive appraisal of the situation determines what the emotion will be. When people incorrectly label the source of the arousal that they are experiencing, we say that they have misattributed their arousal. We communicate and perceive emotion in part through nonverbal communication and through facial expressions. The facial feedback hypothesis proposes that we also experience emotion in part through our own facial expressions. Stress refers to the physiological responses that occur when an organism fails to respond appropriately to emotional or physical threats. The general adaptation syndrome describes the three phases of physiological change that occur in response to long-term stress: alarm, resistance, and exhaustion. The stress that we experience in our everyday lives, including daily hassles, can be taxing. People who experience strong negative emotions as a result of these hassles exhibit more negative stress responses those who react in a less negative way. On average, men are more likely than are women to respond to stress by activating the fight-or- flight response, whereas women are more likely to respond using the tend-and-befriend response. It is healthier to let out the negative thoughts and feelings by expressing them, either to ourselves or to others. It is easier to respond to stress if we can interpret it in more positive ways—for instance, as a challenge rather than a threat. Regulating emotions takes effort, but the ability to do so can have important positive health outcomes. The best antidote for stress is to think positively, have fun, and enjoy the company of others. People who express optimism, self-efficacy, and hardiness cope better with stress and experience better health overall. Happiness is determined in part by genetic factors such that some people are naturally happier than others, but it is also facilitated by social support—our positive social relationships with others. After a minimum level of wealth is reached, more money does not generally buy more happiness.

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Rawson had lectured to the Arizona Homicide Investigators Association and was known to them as experienced in bitemark analysis erectile dysfunction ultrasound protocol order cheapest viagra soft and viagra soft. Rawson did a comprehensive analysis and developed a videotaped pre- sentation of his analysis and experiments impotence home remedies 100 mg viagra soft purchase overnight delivery. Rawson reportedly stated erectile dysfunction muse discount viagra soft 100 mg online, “Te question should not be are bitemarks as good as fngerprints but are fngerprints as good as bitemarks” (transcript of original trial in State v. In 1995 the Supreme Court of Arizona reversed the decision on procedural grounds and remanded the case for a new trial. Rawson, the state’s expert, prior to the second trial and asked him to reconsider his opinion, Dr. When confronted, he obliquely confessed to the crime, reportedly stating that he only remembered strug- gling with the victim then awakening the next morning with blood on his 324 Forensic dentistry Figure 14. Piakis subsequently had the opportunity of compare Phillips’s dentition to the bitemark and stated that Phillips’s teeth were more consistent with the bitemark than Krone’s. Bitemarks 325 Te case of Ray Krone is a tragic indictment of law enforcement and legal prosecution practices and of the faulty application of bitemark analysis. Tis activity included overstating and overdramatizing the results of tests and experiments and failure to follow accepted guidelines by not seeking second opinions and disregarding or discounting the unsolicited opinions received. Te homicide detectives failed to thoroughly investigate and follow all leads, and the prosecutors exhibited tunnel vision and willingness to shop for expert opinions that supported their theory of the crime. During an inter- view by a prosecutor before the retrial, one defense odontologist remarked, “I hope you have other important evidence … the bitemark evidence is bad” and was bluntly told, “Doctor, this is a bitemark case and has always been a bitemark case. Tis triumvirate committed errors that compounded to produce a gross miscarriage of justice. Tis case is described in detail in a book authored by Jim Rix, Ray Krone’s cousin and the sponsor of his defense. One or more second opinions from other competent forensic odontologists should be sought and considered. Te Supreme Court of Michigan ruled that that type of testimony was inadmissible afer several cases in that state in which bitemarks were associated to a suspect with statements of mathematical degrees of certainty. Te 1991 case of the kidnapping, assault, and rape of Maureen Fournier featured the victim’s eyewitness identifcation of the fve men who participated in the attack and the two who allegedly bit her. Both Michael Cristini and Jefrey Moldowan were convicted based on the victim’s identifcations and two forensic odontologists’ testimony that the bitemark associations were posi- tive. Allan Warnick, testifed that one of the marks was made by Moldowan and the odds that someone else made the mark were 3 million to one. In another case he testifed that “the chances of someone else having made the mark would be 4. Homer Campbell and Richard Souviron independently reviewed the evidence and reported that, in their opinion, Moldowan and Cristini could be excluded. Te court ruled that no testimony regarding mathematical degrees of certainty for bitemarks would be heard. Berman, testifed that Cristini made the bitemark with a high degree of certainty, and the defense expert, Dr. In an unusual twist in this trial, one of the original odontologists for the prosecution in the frst trial in 1991, Dr. Hammel, took the stand for the defense and testifed that she had erred in the original trial. She stated further that she originally had doubts about the orientation of the bitemark, and afer gaining more experience and reviewing the evidence, she realized her error. It took a great deal of courage for her to admit the error, but it was absolutely the right thing to do. Cristini had been arrested and charged with eight counts of frst-degree criminal sexual conduct allegedly involving a fve-year-old child. First, that eyewitness testimony may or may not be accurate—here the victim may have been wrong about the identity of the biters. She accused others that were later proven to be else- where at the time of the crime. Second, there is no scientifc basis for math- ematical degree of certainty with bitemark evidence on skin.

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Euca- lypts were also widely used to ease disordered breathing by breaking up phlegm and reducing the swelling of mucous membranes impotence 28 years old viagra soft 100 mg buy. The settlers investigated the medicinal value of a number of indigenous plants basing their choices on similarities that they observed between these and the European plants with which they were more familiar erectile dysfunction causes prescription drugs purchase viagra soft 50 mg otc. One of the first to be identified as being medicinally useful was a species of eucalyptus (E impotence questions order cheapest viagra soft. The Australian oil has a much stronger smell than its European counterpart and so was used in smaller quantities – happily as it turns out because eucalyptus oil is chemically different from peppermint oil and a great deal more toxic. These often contained small quantities of quinine or other bitter- tasting substances and were used to stimulate saliva flow and thus promote general well-being. Aborigines appeared not to have used their plants for such purposes but the settlers identified – after some trial and error – that a number of Australian plants could substitute for remedies used in Europe. Some plants such as Centaurium spicatum were ‘pleasantly bitter’; others such as bitter bark, Alstonia constrica, were much less pleasant leaving a long-lasting bitter after-taste in the mouth. A number of them appear to have been chosen on the similia similibus curantur or ‘like treats like’ principle, one favoured by many cultures in different regions and at different times. This was especially evident in their choice of some plants Traditional medicines in the Pacific | 277 Figure 10. Plants that grew close to water were thus used to treat those people who had pain or difficulty with urination. Plants such as Euphorbia drummondii, which produced a sticky exudate, were used to treat gonorrhoea, a disease with a pus discharge of similar appearance. The volatile oil, tea tree oil, which is extracted from Melaleuca alternifolia, is widely promoted as an antiseptic, antibacterial and antifungal agent, and is included in numerous cleaning and cosmetic products, as are the oils of many Eucalyptus species. The kangaroo apple bush, Solanum aviculare, is a source of alkaloids related to the steroids produced in the Mexican yam, and which could also become a viable source of the starting materials for oral contraceptive synthesis. These commercial successes, together with the increasing trend in western society to utilise herbal medicines, has revived interest in Australia’s flora and traditional herbal medicine history. A systematic search of infor- mation in Australia’s Northern Territory about Aboriginal use of plants led in 1988 to the compilation of the first Aboriginal pharmacopoeia of the Northern Territories. More recent research has compared the efficacy of certain traditional remedies with western preparations used for the same conditions, and has found them to be at least as effective, especially when used to treat skin problems such as boils and other general surface infections. As traditional remedies are often more acceptable than western ones to some Aboriginal communities, such medi- cines may be used to improve the often very poor general health of people in these communities. It is ironic that a people whose culture is so ancient and who live in a country with a flora that is at least potentially so medicinally active should have such poor health that their life expectancy is almost 20 years less than that of ‘immigrant’ Australians. One of several strategies being employed to help reduce this inequity has been the recent introduction of support for traditional healers and other Aboriginal health workers in Aboriginal communities. The hope is that their use of a combination of traditional and western medicine will help promote a greater sense of ownership, pride and thus self-worth in the people of these communities, and thus ultimately better general health. Fiji It is difficult to determine which of Fiji’s flora are indigenous and which introduced by its human inhabitants. The forest plants seem, however, to be the oldest surviving species while later ones appear to include most of the Traditional medicines in the Pacific | 279 food and medicinally active species. Many of these are not specific to Fiji but are found throughout tropical regions in south-east Asia and the Pacific. Those used by the Indo-Fijian population are generally the ones favoured by the ayurvedic tradition of medicine (discussed in Chapter 7). The health of pre-European Fijians appears to have been generally good, although diseases such as yaws, filariasis, malaria and other fever-producing conditions were recorded. Post-European settlement, however, the Fijians suffered from imported diseases such as gonorrhoea, diphtheria and measles, so much so in fact that it was feared that the population might even die out completely. Early Europeans could obtain little information about plants used as medicines by the local population. One such person writing in the 1860s complained that the women who seemed to have knowledge of medi- cinally useful plants could not be induced to part with this knowledge because it was a source of income for them.

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Another note- worthy example is rootwork among African–Americans that generally perplexes those who have not been alerted to its existence impotence grounds for divorce states discount 100 mg viagra soft with visa. Moreover erectile dysfunction in diabetes patients buy viagra soft with mastercard, less tangible matters must not be overlooked in consid- ering persistence of beliefs erectile dysfunction pills wiki discount viagra soft 100 mg buy on-line, e. Although such a mystique contributes to a ‘pedigree’ of empirical knowledge, it must be pointed out that relatively few plants used by North American aboriginal peoples had a lasting impact on North American and European professional medical prac- tice – as distinct from domestic usage – which raises doubts about the general effectiveness of many of them, even black cohosh. As noted, not only is there a history of uncertainty, even when black cohosh was in fashion, but also there are issues over current promotion that selects information to support a case, or even over ‘reading’ uses into older texts to support current views on a substance’s reputation in menopausal symptoms. In the current climate of practice, a practitioner has a responsibility to provide the pros and cons for the use of a treatment giving a critical evaluation of non-scientific as well as scientific data. Magico-religious/spiritual practices Introductory comments As problematic as the critical appraisal of information on herbs can be, some practitioners may find greater difficulty in responding to queries about what have long been called magico-religious, magical and spiritual practices. Nowadays, the distinction between these categories is commonly blurred, because they depend on how supernatural forces are viewed by individuals. Although this chapter is not concerned with Mexican traditional prac- tices, they have become part of other North American countries to which Mexicans migrated. Magico-religious practices commonly embrace beliefs in supernatural influences; these include shamanism, in which a shaman, in the context of healing, can act as a medium for an entering spirit (maybe the spirit of a renowned ancestral healer) to ‘orchestrate’ the care through the healer. On the other hand, some will describe, say, the charming away of warts as merely ‘magical’, meaning a magical circumstance – a view perhaps influ- enced by a popular idea of a healer as someone who is able to help a person develop their own inherent healing powers, or, as some might say, enhancing ‘the power of the mind over the body’. The ‘power’ (or skill) of some such healers may be viewed as a result of a deep knowledge of traditions, perhaps including the ability to make spiritual connections – in other words, divorced from being able to control supernatural forces. It is incumbent on a practitioner responding to the question from a patient about a ceremony (perhaps an aboriginal person looking to reconnect with traditional ways) to appreciate the spectrum of ceremonies and how they may help with specific physical, mental or psychological problems. To do so 56 | Traditional medicine demands reflection on one’s own attitudes as well as an appreciation of the nature of the main ceremonies (step 1). It is certainly as well to remember that conventional medicine has long looked upon magical practices as lacking credibility, certainly since the seventeenth to eighteenth centuries when supernatural practices were increasingly expunged from regular treatments. In fact, this trend joined the growing scepticism, on the part of many practitioners, of the value of numerous herbal treatments including those used by aboriginal peoples. For instance, in 1897 James Mooney indicated that only 25% of an admittedly small group of Cherokee plants were used correctly (see Hamel and Chiltosky,18 page 6). Step 1 (preparation): the placebo effect Before noting some features of healing ceremonies (the sweat lodge as an example) that can be useful for a practitioner in discussions with patients, it is helpful to reflect on a reason commonly heard today for paying little attention to aboriginal treatments, namely that any benefit is ‘merely a placebo effect’. With this new role, physicians began to feel that it was unethical to prescribe a placebo consciously – as had previously been fairly common (the proverbial ‘bottle of coloured water’, although attacked at times) – either as ‘fake’ treatment or as one unsupported by clinical trial data. It is noteworthy that the change in attitudes from before the 1950s seemingly occurred without general discussion on the potential to diminish placebo effects that benefited patients. Having said this, it is as well to appreciate that, since writing this, some change in attitudes might be under way. At least a British Medical Journal editorial (3 May 2008) strongly hinted that the placebo effect may be one of the most ‘added value’ tools in the medical bag. This applies to healing ceremonies although they are often acknowledged to have poten- tial psychological effects for some participants, perhaps associated with the power of the ritual (see below). Moreover, many facets of healing ceremonies resonate with those viewed as essential for effective therapeutic relationships: Aboriginal/traditional medicine in North America | 57 mutually held beliefs between practitioner and patient, a patient’s trust, elements of hope and other factors with a potential to foster a placebo effect. Given this, a conventional practitioner may want to consider seriously whether to positively support a healing ceremony, or indeed for it to become a part of integrated care for an aboriginal person living in an urban situation and looking to try a traditional practice. The sweat lodge: some key points for step 2 discussion The sweat lodge is chosen to illustrate certain points that can be useful when responding to a patient who asks whether a healing ceremony might be helpful, as well as for exploring their expectations. The sweat lodge is where you can talk openly about how you feel about alcoholism, family abuse or whatever. Whenever you have difficulty, you know there will always be people in the circle who do care about you, and do care if you survive or not, and do care for your family. And, too, I’ve heard a lot of talk from older people on how it helps not only the spiritual part, but also aches and pains. These words from the chief of a Mi’kmaq reserve, where the sweat lodge ceremony was recently introduced (after being in limbo for generations) as part of the revitalisation of traditional ways and values, reflects both the widespread use of the lodge to help with sociomedical problems (e.

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Worksheet 4-9 My Mood Diary Day Feelings and Sensations (Rated 1–100) Corresponding Events Sunday Monday Tuesday Wednesday Thursday Friday Saturday Visit www erectile dysfunction medicine bangladesh viagra soft 50 mg free shipping. Part I: Analyzing Angst and Preparing a Plan 50 Worksheet 4-10 My Reflections Becoming a Thought Detective Imagine yourself in a parking lot at night erectile dysfunction caused by spinal stenosis buy viagra soft overnight. Or do you feel dis- traught and upset with yourself because you believe you were careless? However age related erectile dysfunction causes viagra soft 100 mg for sale, if your thoughts are intense or persistent, they provide clues about your negative thinking habits. These habits dictate how you interpret the accident and thus the way you feel about it. If you feel terribly worried, it’s probably because you tend to have lots of anxious thoughts. If the acci- dent leaves you overly down on yourself, you may be prone to depressive thoughts. Thought Trackers show you how feelings, events, and thoughts connect — they lay it all out for you. See how Molly, Tyler, and Jasmine complete their Thought Trackers before you try a few for yourself. Her psychologist has been having her fill out Thought Trackers for the past week whenever she notices upsetting feelings. So later that night she completes a Thought Tracker on the incident (see Worksheet 4-11). Worksheet 4-11 Molly’s Thought Tracker Feelings and Sensations (Rated 1–100) Corresponding Events Thoughts/Interpretations Despair (70); nauseous Crunched my I can’t believe I did that. Tense (90); tightness through I don’t have time to deal my back and shoulders with this. I’ll have to call the insurance company, get estimates on the repair, and arrange alternative transportation. Chapter 4: Minding Your Moods 51 Strange as it may seem, Tyler slams his car into that same pole, although not until the next night. He also fills out a Thought Tracker on the incident (see Worksheet 4-12), having read about them in the Anxiety & Depression Workbook For Dummies. Worksheet 4-12 Tyler’s Thought Tracker Feelings and Sensations (Rated 1–100) Corresponding Events Thoughts/Interpretations Rage (80); flushed face and I hit that stupid There’s not a single good rapid breathing pole with my new reason that anyone sports car. Now, you’re going to find this really hard to believe, but Jasmine happens to be in that same parking lot a week later. Like Molly and Tyler, Jasmine com- pletes a Thought Tracker (see Worksheet 4-13) following her run-in with that pesky pole. Worksheet 4-13 Jasmine’s Thought Tracker Feelings and Sensations (Rated 1–100) Corresponding Events Thoughts/Interpretations Panic (95); terrified, sweaty, I slammed my At first I thought I might rapid shallow breathing, dizzy car into a pole. All three of them look at this event in unique ways, and they feel differently as a result. Because of the way she interprets the event, Molly’s at risk for anxiety and depression. On the other hand, Jasmine panics about the bash into the pole; her reaction is the product of her frequent struggles with anxiety and panic. Part I: Analyzing Angst and Preparing a Plan 52 Sometimes people say they really don’t know what’s going on in their heads when they feel distressed. They know how they feel and they know what happened, but they simply have no idea what they’re thinking. If so, ask yourself the ques- tions in Worksheet 4-14 about an event that accompanied your difficult feelings. Chapter 4: Minding Your Moods 53 The Thought Tracker demonstrates how the way you think about occurrences influences the way you feel. Sad feelings inevitably accompany thoughts about loss, low self-worth, or rejection. Anxious or worried feelings go along with thoughts about danger, vulnerability, or horrible outcomes. Pay attention to your body’s signals and write them down whenever you feel some- thing unpleasant. Refer to the Daily Unpleasant Emotions Checklist earlier in this chapter for help. Rate your feeling on a scale of intensity from 1 (almost undetectable) to 100 (maximal).

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Most chapters about particular nursing theories are written by the theo- rists themselves erectile dysfunction causes symptoms and treatment discount viagra soft 100 mg with visa. Some chapters are written by nurses with advanced knowledge about particular nursing theories; these authors have been acknowledged by specific theorists as experts in pre- senting their work erectile dysfunction otc treatment order viagra soft now. Each chapter also includes illustratrations of the use of the theory in nurs- ing practice erectile dysfunction at age 64 generic viagra soft 100 mg without a prescription, research, education, or administration. Each author writes about research and development of middle-range or nursing practice theory and about exploration of theory in the personal and professional contexts. The political and economic dimensions of one of the theories in contem- porary nursing practice is illustrated. Peplau’s Process of Practice-based Theory Development and Its Applications 58 Ann R. Parker Definitions of Nursing Theory Nursing Theory in the Context of Nursing Knowledge Types of Nursing Theory Nursing’s Need for Nursing Theory Nursing Theory and the Future Summary References Florence Nightingale taught us that nursing the- acute care settings is rapidly changing. Various par- ories describe and explain what is and what is not adigms and value systems that express perspectives nursing (Nightingale, 1859/1992). Today, knowl- held by several groups within the discipline ground edge development in nursing is taking place on sev- the knowledge and practice of nursing. Because the eral fronts, with a variety of scholarly approaches language of nursing is continually being formed contributing to advances in the discipline. Nursing and distinguished, it often seems confusing, as does practice increasingly takes place in interdisciplinary any language that is new to the ears and eyes. This chapter offers an approach to under- a more open definition of theory as a “construct standing nursing theory within the context of nurs- that accounts for or organizes some phenomenon,” ing knowledge. It reviews the types of nursing and states simply that a nursing theory describes or theory and advances reasons why theory is so explains nursing. The chapter closes with Definitions of theory emphasize various aspects an invitation to share with contributing authors of of theory and demonstrate that even the concep- this book their visions of nursing theory in the tions of nursing theory are various and changing. Definitions of theory developed in recent years are more open and less structured than definitions cre- ated before the last decade. Not every nursing the- Definitions of Nursing Theory ory will fit every definition of what is a nursing theory. For purposes of nursing practice, a defini- A theory, as a general term, is a notion or an idea tion of nursing theory that has a focus on the that explains experience, interprets observation, meaning or possible impact of the theory on describes relationships, and projects outcomes. The following definitions of Parsons (1949), often quoted by nursing theorists, theory are consistent with general ideas of theory in wrote that theories help us know what we know nursing practice, education, administration, or re- and decide what we need to know. As such, theories are lationships among concepts for purposes of describing, explaining, predicting, and/or con- Theories are not discovered in nature but trolling phenomena (Chinn & Jacobs, 1987, are human inventions. For these • Nursing theory is a conceptualization of some reasons, theory and related terms have been defined aspect of reality (invented or discovered) that and described in a number of ways according to in- pertains to nursing. A theory, • Nursing theory is an inductively and/or deduc- by traditional definition, is an organized, coherent tively derived collage of coherent, creative, and set of concepts and their relationships to each other focused nursing phenomena that frame, give that offers descriptions, explanations, and predic- meaning to , and help explain specific and selec- tions about phenomena. The scribe the importance of relating theories that have concept of paradigm comes from the work of Kuhn been developed at these various levels of abstrac- (1970, 1977), who used the term to describe mod- tion. Kuhn set forth the view that is, it must be continually in process and useful that science does not evolve as a smooth, regular, for the purposes and work of the discipline. It must continuing path of knowledge development over be open to adapting and extending in order to time, but that there are periodic times of revolution guide nursing endeavors and to reflect develop- when traditional thought is challenged by new ment within nursing. In addition, opinion among nurses about terms used to de- Kuhn’s work has meaning for nursing and other scribe theoretical development, the following dis- practice disciplines because of his recognition that cussion of types of theoretical development in science is the work of a community of scholars in nursing is offered as a context for further under- the context of society. The metaparadigm is as new perspectives are being articulated, some tra- very general and is intended to reflect agreement ditional views are being strengthened, and some among members of the discipline about the field views are taking their places as part of our history. This is the most abstract level of nurs- ing knowledge and closely mirrors beliefs held about nursing. The metaparadigm offers a context As we continue to move away from the for developing conceptual models and theories. All nurses have some awareness of nursing’s As we continue to move away from the historical metaparadigm by virtue of being nurses. However, conception of nursing as a part of medical science, because the term may not be familiar, it offers no developments in the nursing discipline are directed direct guidance for research and practice (Walker & by several new worldviews.

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An alternative is to convert the alcohol into alkyl halide or alkyl tosylate (see below) erectile dysfunction tips discount generic viagra soft canada, which has a much 5 erectile dysfunction watermelon purchase discount viagra soft. Acid-catalysed condensation of alcohols: preparation of ethers Bimolecular dehydration is generally used for the synthesis of symmetrical ethers from unhindered 1 alcohols erectile dysfunction gnc products cheap viagra soft 100 mg on-line. In this reaction, ethanol 2 4 is protonated in the presence of an acid, which is then attacked by another molecule of ethanol to give diethyl ether. Without the use of ZnCl , the S 2 reaction is 2 N slow, because chloride is a weaker nucleophile than bromide. The ZnCl2 coordinates to the hydroxyl oxygen, and generates a better leaving group. Thionyl chloride converts the hydroxyl group in an alcohol to a chlorosulphite leaving group that can be displaced by the chloride. This type of reaction does not lead to rearranged products, and does not work well with 3 alcohols. The hydroxyl oxygen displaces a halide, a good leaving group, from the phosphorus. The halide attacks the backside of the alkyl group and displaces the positively charged oxygen, which is a good leaving group. Tosylate esters (alkyl tosylates) are formed from alcohols from the reaction with p-toluenesulphonyl chloride (TsCl). Although an epoxide and an ether have the same leaving group, epoxides are more reactive than ethers due to ring strain in the three membered ring. Thus, epoxides are synthetically useful reagents, and they react with a wide variety of nucleophiles. Cleavage of ethers and epoxides by haloacids Preparation of alkyl halides Ethers can be cleaved at the ether linkage only at high temperatures using haloacids, e. Protonation of the oxygen in ether creates a good leaving group, a neutral alcohol molecule. The oxygen is protonated to form a protonated ethylene oxide, which, being attacked by the halide, gives bromoethanol. For example, hydrolysis of ethylene oxide in the presence of acid-catalyst produces 1,2-ethanediol (ethylene glycol). For example, propylene oxide reacts with alcohol in the presence of acid to give 2-methoxy-1-propanol. For example, propylene oxide is an unsymmetrical epoxide, which reacts with methyl magnesium bromide to produce 2-butanol, after the acidic work-up. Nucleophilic acyl substitution can interconvert all carboxylic acid derivatives, and the reaction mechanism varies depending on acidic or basic conditions. Under acidic conditions, the carbonyl group becomes protonated, and thus is activated towards nucleophilic acyl substitution. A simultaneous deproto- nation and loss of the leaving group reforms the carbonyl CÀÀÀÀO double bond. The equilibrium can be driven to completion by using an excess of the alcohol, or by removing the water as it forms. The carbonyl group of a carboxylic acid is not sufficiently electrophilic to be attacked by the alcohol. The acid catalyst protonates the carbonyl oxygen, and activates it towards nucleophilic attack. The alcohol attacks the protonated carbonyl carbon, and forms a tetrahedral intermedi- ate. Intramolecular proton transfer converts the hydroxyl to a good leaving group as H2O. This is where the alcohol part of the ester can be replaced with a new alcohol component. For example, acetic anhydride is prepared industrially by heating acetic acid to 800 C. Other anhydrides are difficult to prepare directly from the corresponding carboxylic acids.

Angir, 45 years: That’s where the lymphatic system steps in, forming an alternative route for the return of tissue fluid to the bloodstream.

Mojok, 35 years: Some small amounts of alcohol included in many medicines may be patients have seizures (‘rum fits’ generally 12–48 hours post sufficient to produce a reaction and it is advisable for the abstinence).

Bogir, 39 years: New York: Basic maintaining the patient’s respiratory and cardiac func- Books, 1992.

Daryl, 33 years: For example, the prescriber might write a med- ication order for 800 mg of ibuprofen.

Denpok, 31 years: It is often acquired from the patient’s own gas- ovarian carcinoma treated with alkylating agents with or tro-intestinal tract flora.

Muntasir, 41 years: It is a common occurrence for the elderly due to insufficient water intake and poor dietary habits.

Irmak, 50 years: Statement on exercise, benefits and recommendations for physical activity programs for all Americans.

Sanford, 55 years: Receptor cells on the retina are excited or inhibited by the light and send information to the visual cortex through the optic nerve.

Curtis, 59 years: Te anthropolo- gist may supervise and document the process, collecting relevant samples, e.

Lares, 22 years: This drug can improve your chances of a full recovery, but it is effective only if given within three hours of initial symptoms.

Kaelin, 51 years: Consistent with this caring base is Nightingale’s views on nursing as an art and a science.

Musan, 29 years: Shearing forces, pushing the walls of capillaries together by folding the skin over, increases the (blood) pressure needed to open capillaries (Matlhoko 1994).

Vasco, 60 years: Furthermore, the rate of drug dissolution, that is, the rate at which a solid drug dissolves in the aqueous medium, controls its activity when a solid drug is administered by enteral routes (see Section 2.

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