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If a detainee with known epilepsy has a seizure while in custody purchase hydroxyzine 10 mg line, a medical assess- ment is advisable purchase hydroxyzine 25 mg with visa, although there is probably no need for hospitalization. How- ever, if a detainee with known epilepsy has more than one fit or a detainee has a “first-ever” fit while in custody, then transfer to a hospital is recommended. Diazepam intravenously or rectally is the treatment of choice for status epilepticus (11). Any detainee requiring parenteral medication to control fits should be observed for a period in the hospital. Asthma Asthma is a common condition; a careful history and objective recording of simple severity markers, such as pulse and respiratory rate, blood pressure, speech, chest auscultation, mental state, and peak expiratory flow rate, should identify patients who require hospitalization or urgent treatment (Table 4) (12). Detainees with asthma should be allowed to retain bronchodilators for the acute relief of bronchospasm (e. Diabetes It is often desirable to obtain a baseline blood glucose measurement when detainees with diabetes are initially assessed and for this to be repeated if necessary throughout the detention period. All doctors should have the means to test blood glucose, using either a strip for visual estimation or a quantitative meter. Oral hypoglycemics and insulin should be continued and consideration given to supervision of insulin injections. Regular meals and snacks should be provided, and all patients with diabetes should have access to rapidly absorbed, carbohydrate-rich food. If the blood glucose is less than 4 mmol/L in a conscious person, oral carbohydrates should be given. In a detainee who is 210 Norfolk and Stark unconscious or restless, an intravenous bolus of 50 mL of 50% dextrose solu- tion may be difficult to administer and may result in skin necrosis if extravasa- tion occurs; therefore, 1 mg of glucagon can be given intramuscularly, followed by 40% glucose gel orally or applied to the inside of the mouth. Glucagon can give an initial glycemic response even in a patient with alcoholic liver disease (13); however, it should be remembered that in severe alcoholics with depleted glycogen stores, the response to glucagon may be reduced or ineffective. Heart Disease The main problems encountered include a history of hypertension, angina, cardiac failure, and stable dysrhythmias. Basic cardiovascular assessment may be required, including examination of the pulse and blood pressure, together with auscultation of the heart and lungs for evidence of murmurs or cardiac failure. Prescribed medication should be continued, and detainees should be allowed to keep their glyceryl trinitrate spray or tablet with them in the cell. Chest pain that does not settle with glyceryl trinitrate will obviously require further assessment in the hospital. Sickle Cell Disease Most detainees with sickle cell disease are aware of their illness and the symptoms to expect during an acute sickle cell crisis. Medical management in custody should not pose a problem unless there is an acute crisis, when hospital transfer may be required. Conditions of detention should be suitable, with adequate heating and access to fluids and analgesics as appropriate. General Injuries Detailed documentation of injuries is an important and common request. The injuries may have occurred before or during the arrest, and documenta- tion of such injuries may form part of the investigation to refute counter alle- gations of assault. A record of each injury, as outlined in Chapter 4, should be made and basic first aid provided. Certain wounds may be treated with Steri-Strips or Histo- acryl glue in the police station (14), although occasionally transfer to a hospital will be required for further medical assessment (e. Head Injuries Any suspected head injury should receive a detailed assessment (15). The time, place, and nature of the injury should be ascertained from the detainee or from any witnesses who were present. Examination should include measurement of pulse and blood pressure, Glasgow Coma Scale (16), and neurological assessment. The indications for hospital assessment include situations in which there are problems with the assessment of the patient or an increased risk of skull fracture or an intracranial bleed (Table 5) (17). Ingestion of alcohol or drugs and relevant past medical history should be ascertained. Although deaths in police custody are rare, head injuries accounted for 10% and substance abuse, including alcohol and drugs, accounted for 25% in a survey of such deaths between 1990 and 1997 in England and Wales (18). There should be a low threshold for referral to hospitals, especially if a detainee with a head injury is also under the influence of alcohol or drugs.

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Initially the dogs salivated only when they saw or smelled the food buy 10 mg hydroxyzine visa, but after several pairings of the sound and the food buy hydroxyzine 10 mg with visa, the dogs began to salivate as soon as they heard the sound. Pavlov had identified a fundamental associative learning process called classical conditioning. After the association is learned, the previously neutral stimulus is sufficient to produce the behavior. Top right: Before conditioning, the neutral stimulus (the whistle) does not produce the salivation response. Conditioning is evolutionarily beneficial because it allows organisms to develop expectations that help them prepare for both good and bad events. Imagine, for instance, that an animal first smells a new food, eats it, and then gets sick. The Persistence and Extinction of Conditioning After he had demonstrated that learning could occur through association, Pavlov moved on to study the variables that influenced the strength and the persistence of conditioning. Extinctionrefers to the reduction in responding that occurs when the conditioned stimulus is presented repeatedly without the unconditioned stimulus. Pavlov found that, after a pause, sounding the tone again elicited salivation, although to a lesser extent than before extinction took place. If conditioning is again attempted, the animal will learn the new associations much faster than it did the first time. Pavlov also experimented with presenting new stimuli that were similar, but not identical to, the original conditioned stimulus. For instance, if the dog had been conditioned to being scratched before the food arrived, the stimulus would be changed to being rubbed rather than scratched. He found that the dogs also salivated upon experiencing the similar stimulus, a process known as generalization. Generalization refers to the tendency to respond to stimuli that resemble the original conditioned stimulus. If we eat some red berries and they make us sick, it would be a good idea to think twice before we eat some purple berries. Although the berries are not exactly the same, they nevertheless are similar and may have the same negative properties. In his experiment, high school students first had a brief interaction with a female experimenter who had short hair and glasses. The study was set up so that the students had to ask the experimenter a question, and (according to random assignment) the experimenter responded either in a negative way or a neutral way toward the students. Then the students were told to go into a second room in which two experimenters were present, and to approach either one of them. However, the researchers arranged it so that one of the two experimenters looked a lot like the original experimenter, while the other one did not (she had longer hair and no glasses). The students were significantly more likely to avoid the experimenter who looked like the earlier experimenter when that experimenter had been negative Attributed to Charles Stangor Saylor. The participants showed stimulus generalization such that the new, similar-looking experimenter created the same negative response in the participants as had the experimenter in the prior session. The flip side of generalization is discrimination—the tendency to respond differently to stimuli that are similar but not identical. Pavlov‘s dogs quickly learned, for example, to salivate when they heard the specific tone that had preceded food, but not upon hearing similar tones that had never been associated with food. Discrimination is also useful—if we do try the purple berries, and if they do not make us sick, we will be able to make the distinction in the future. And we can learn that although the two people in our class, Courtney and Sarah, may look a lot alike, they are nevertheless different people with different personalities. In some cases, an existing conditioned stimulus can serve as an unconditioned stimulus for a pairing with a new conditioned stimulus—a process known as second-order conditioning. Eventually he found that the dogs would salivate at the sight of the black square alone, even though it had never been directly associated with the food. Secondary conditioners in everyday life include our attractions to things that stand for or remind us of something else, such as when we feel good on a Friday because it has become associated with the paycheck that we receive on that day, which itself is a conditioned stimulus for the pleasures that the paycheck buys us. The Role of Nature in Classical Conditioning As we have seen in Chapter 1 "Introducing Psychology", scientists associated with the behavioralist school argued that all learning is driven by experience, and that nature plays no role.

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Many herbs are now cultivated rather than picked from the wild cheap 25 mg hydroxyzine free shipping, not only protecting the environ- ment discount 25mg hydroxyzine with mastercard, but also making it possible to control growing conditions. This is a far cry from the previous situation, Traditional Chinese medicine | 171 where most herbs would be purchased from central markets dotted around the country. Accidental contaminants may also include allergens, pollen, insect parts, moulds and mould spores. There are both intrinsic adverse reactions resulting from the toxicity of the product and extrinsic adverse reactions arising from ancillary procedures, e. To minimise the chance of adverse reactions leading to a recur- rence of the circumstances surrounding the use of Aristolochia with other herbs, the following measures should be instigated: • Quality assurance and quality control should be put in place to ensure that unadulterated herbs are supplied to manufacturers and practitioners. This is in any case a minimum requirement for the collection of the evidence of successful outcomes required by purchasing authorities. Effective use of the Yellow Card system by all disciplines of complementary medicine is long overdue. Non-medically qualified practitioners (‘professional practitioners’) should also be encouraged to take part. Although Chinese herbs have a long established history of use there is still relatively little present-day information on herbal safety. Yes/No 3) About the herbal medicine(s) that you think caused the adverse reaction Type of prescription: Raw herbs/Concentrated Powder/Tincture/Pills/Cream/ (Delete as appropriate) or other (please describe)........................................................................................................................................ Yes/No Please describe the suspected adverse reaction in your own words including any treatment received for the reaction.......................................................................................................................................... Yes/No 5) More information about the person who had the adverse reaction Other medical conditions including known sensitivities.......................................................................... Yes/No/Don’t know (please delete as appropriate) If yes, did the health professional complete a Yellow Card report? Yes/No/Don’t know (please delete as appropriate) Please give any other information that you think might be relevant including test results, oriental medical diagnosis e. For congenital abnormalities please state all other drugs taken during pregnancy and the last menstrual period. If you wish for your Yellow Card report to be sent for analysis then please enclose a copy of your full case history notes and tick this box 9) Finally, please sign and date this Yellow Card submission, thank you. This does not include minor known side effects such as loose stools with the use of greasy yin tonics, or any other symptom that you might warn your patient about as a mild transient side effect. Sometimes it is hard to tell whether a possible adverse reaction is due to herbs prescribed or something else. However, even if a practitioner is unsure as to whether a herbal medicine or a combination of herbal medicines and other medicines has caused a side effect, but has a suspicion, completion of a card would be appropriate. Endangered species The conservation of rare medicinal plants is a worldwide problem affecting many cultures. Researchers at Bastyr University are studying the issue of endangered species usage in depth, along with the issues of excessive toxins, drugs, adulterants, and illegal and inaccurate labelling practices, which are prevalent in these formulae. Bastyr University is near Seattle, and integrates the pursuit of scientific knowledge with the wisdom of ancient healing methods and traditional cultures from around the world. Researchers plan to work with the manufacturers of Chinese herbal patent formulae toward establishing guidelines that may be implemented in the west and in Asia. This has resulted in the now widespread use of concentrated powder and granule extracts. These products are proving popular with both western patients and in Chinese cities where the pace of life has recently increased significantly. Although there is no doubt that these products make the process of taking herbal medicine much easier and therefore patient compliance has certainly improved, traditionalists argue that the effectiveness of these products is less than when using raw herbs. Until more comparable research is undertaken it will remain a matter of practitioner preference. Traditionally made powders are produced from grinding the raw herb and can have very high microbial loads. As a result of the heating steps involved in the manufacture of concentrated extracts, the microbiological loading will be close to zero. In many western cities the Chinatown districts support herb shops and practices with remedies imported directly from Asia, and practitioners trained by the old system of long apprenticeship.

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It was shown that hydroxyzine 25mg otc, al- Economic Implications though the acuity of hospitalized patients in- of Bureaucratic Caring creased discount hydroxyzine 10 mg without prescription, the average length of stay dropped from 9. Nursing produc- Theory: Research in tivity improved and quality of care scores increased Current Atmosphere with the increased registered nurse staffing. The of Health-Care Reform higher costs of employing registered nurses was off- set by the productivity gains, and the hospitals net- Investigation of the economic dimension of bu- ted an average of 55 percent productivity savings reaucratic caring is being explicated in part in nurs- (Helt & Jelinek, 1988). Findings from these research Hospital administrators had made budgeting studies have been valuable when linking the con- and operating decisions based on the undocu- cepts of politics, economics, caring, cost, and qual- mented belief that nursing care accounted for 30 ity in the new paradigm of health-care delivery. However, Although caring and economics may seem para- documented nursing research showed this assump- doxical, contemporary health-care concerns em- tion to be in error. A study conducted at Stanford phasize the importance of understanding the cost University Hospital found that actual nursing costs of caring in relation to quality. Similarly, the Ray (1981, 1987, 1989), Ray and Turkel (2000, Medicus Corporation funded a study in which data 2001, 2003), Turkel (1997, 2001), and Valentine were collected from 22 hospitals and 80,000 patient (1989, 1991, 1993) have examined the paradox be- records. Direct nursing care costs represented, tween the concepts of human caring and econom- on average, only 17. However, any bursement and operating room nursing costs, efforts to reshape the health-care system in our nursing represented only 11 percent of the total country must take into account the value of caring. Nyberg’s (1990) research findings indicated that By the time nursing researchers had demon- nurses were extremely frustrated over the economic strated the difficulty of costing out caring activities pressures of the past five years but that human care with patient classification systems and the effective- was present in nurses’ day-to-day practice. With the nurses see human care as their responsibility and introduction of managed care and increased corpo- goal. One ment was changing faster than nurse researchers nurse administrator proposed “caring as the mis- could document the impact of these changes on sion of the hospital with economic and manage- clinical practice. Although there were organiza- industry is now faced with a shortage of registered tional differences, results showed a high correlation nurses. According to statistics provided by the of caring attributes among the various settings. Department of Interviews conducted with nurses indicated a con- Health and Human Services (2000), over the next cern that their “ability to be caring was in jeopardy. These nurses felt that the practice these studies did not merge economic concepts into of caring was being seriously threatened by the nursing research or theory. As the nursing practice economic pressure associated with health-care environment has continued to change, new re- changes. Foa (1971), an ex- Narrative examples of the attribute, exchanging change theorist, designed an economic theory that commodity values, were “making caring tangible” and “patient care is a commodity (economic good could bridge the gap between economic and or value). In this model, noneco- gotiating the politics were “the nurse administrator nomic resources (love, status, and information) is a system coordinator, nurses are the system and were correlated with economic resources (money, know what impinges on them,” and “nurses are po- goods, and services). The philosophical framework of quality care is located in the reciprocal actions of the economic dimension of bureaucratic caring has the interpersonal nurse-patient relationship served in part as the basis for this type of needed (Hoggard-Green, 1995). Turkel (1997) interviewed nurses, ethnographic approach to study nurse-patient in- patients, and administrators from the for-profit teractions in the critical care environment. The sector to examine the process involved in the devel- subsequent theme generated among all categories opment of the nurse-patient relationship as an of interaction was the nurse-patient relationship. This research was conducted a qualitative study, Price (1993) examined the as managed care penetration was having an enor- meaning of quality nursing care from the perspec- mous impact on the current health-care delivery tive of parents of hospitalized children. The basic ing as a result of health-care reform and managed care, nurses are finding themselves in a period of transition, moving from traditional in-patient hos- The basic social process of the nurse- pital practice to community-based practice. In a re- patient relationship as an economic re- search study conducted by Turkel, Tappen, and Hall source was struggling to find a balance, (1999), the development of a positive nurse-patient which referred to sustaining the caring relationship was shown to be seen as a reward for ideal in a new reality controlled by costs. The research’s long-term goal qualitative interviews were accomplished in not- is to establish caring as an economic interpersonal for-profit and military sectors of the health-care resource. The purpose of this research was to through empirical nursing research, that hospitals continue the study of the nurse-patient relation- with a higher organizational caring score have in- ship as an economic interpersonal resource. Findings from this study identified that the nurse- patient relationship was both outcome and process.

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