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For example discount 2mg zanaflex fast delivery, coping with relationship conflict could involve leaving the relationship or developing strategies to make the relationship better zanaflex 2 mg. In contrast it could involve lowering one’s expectations of what a relationship should be like zanaflex 2mg visa. Lazarus and Folkman (1984) emphasized the dynamic nature of coping which involves appraisal and reappraisal buy generic zanaflex 2 mg online, evaluation and re-evaluation. Likewise, coping is also seen as a similar interaction between the person and the stressor. Further, in the same way that Lazarus and colleagues described responses to stress as involving primary appraisal of the external stressor and secondary appraisal of the person’s internal resources coping is seen to involve regulation of the external stressor and regulation of the internal emotional response. To reduce stressful environmental conditions and maximize the chance of recovery; 2. Styles, processes and strategies When discussing coping, some research focuses on ‘styles’, some on ‘processes’ and some on ‘strategies’. However, it also reflects an ongoing debate within the coping literature concerning whether coping should be considered a ‘trait’ similar to personality, or whether it should be considered a ‘state’ which is responsive to time and situation. The notion of a ‘style’ tends to reflect the ‘trait’ perspective and suggests that people are quite consistent in the way that they cope. The notions of ‘process’ or ‘strategy’ tends to reflect a ‘state’ perspective suggesting that people cope in different ways depending upon the time of their life and the demands of the situation. Some differentiate between approach and avoidance coping, whilst others describe emotion focused and problem focused coping. Approach versus avoidance Roth and Cohen (1986) defined two basic modes of coping, approach and avoidance. Approach coping involves confronting the problem, gathering information and taking direct action. People tend to show one form of coping or the other although it is possible for someone to manage one type of problem by denying it and other by making specific plans. Some researchers have argued that approach coping is consistently more adaptive than avoidant coping. However, research indicates that the effectiveness of the coping style depends upon the nature of the stressor. For example, avoidant coping might be more effective for short-term stressors (Wong and Kaloupek 1986), but less effective for longer-term stressors (Holahan and Moos 1986). Some researchers have also explored repressive coping (Myers 2000) and emotional (non) expression (Solano et al. Problem focused versus emotion focused (also known as instrumentality – emotionality) In contrast to the dichotomy between approach and avoidant coping, the problem and emotion focused dimensions reflect types of coping strategies rather than opposing styles. People can show both problem focused coping and emotional focused coping when facing a stressful event. Problem focused coping: This involves attempts to take action to either reduce the demands of the stressor or to increase the resources available to manage it. Examples of problem focused coping include devising a revision plan and sticking to it, setting an agenda for a busy day, studying for extra qualifications to enable a career change and organizing counselling for a failing relationship. Emotion focused coping: This involves attempts to manage the emotions evoked by the stressful event. Examples of behavioural strategies include talking to friends about a problem, turning to drink or smoking more or getting distracted by shopping or watching a film. Examples of cognitive strategies include denying the importance of the problem and trying to think about the problem in a positive way. Several factors have been shown to influence which coping strategy is used: Type of problem: Work problems seem to evoke more problem focused coping whereas health and relationship problems tend to evoke emotion focused coping (Vitaliano et al. Age: Children tend to use more problem focused coping strategies whereas emotion focused strategies seems to develop in adolescence (Compas et al. Gender: It is generally believed that women use more emotion focused coping and that men are more problem focused.

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For example an attitude to smoking is made up of the belief ‘smoking will lead to lung cancer’ and the belief ‘lung cancer is unpleasant’ generic zanaflex 2mg. This is calculated by multiplying one belief with the other to create a ‘multiplicative composite’ cheap zanaflex 2 mg with amex. In subsequent analysis this new variable is sim- ply correlated with other variables purchase zanaflex 2mg amex. French and Hankins (2003) argue that this is problematic as the correlation between a multiplicative composite and other vari- ables requires a ratio scale with a true zero generic zanaflex 2 mg otc. As with other psychological constructs, the ‘expectancy value belief has no true zero only an arbitrary was chosen by the researcher’. First, it has been suggested these models are not that successful at predicting behavioural intentions and that they should be expanded to incorporate new cog- nitions. Second, it has been argued that they are even less successful in predicting actual behaviour. This second criticism has resulted in research exploring the intention– behaviour gap. Predicting intentions: the need to incorporate new cognitions Sutton (1998a) argued that studies using models of health beliefs only manage to predict between 40 and 50 per cent of the variance in behavioural intentions. Expanded norms The theory of reasoned action and the theory of planned behaviour include measures of social pressures to behave in a particular way – the subjective norms variable. For example, the intention to carry out behaviours that have an ethical or moral dimen- sion such as donating blood, donating organs for transplant, committing driving offences or eating genetically produced food may result from not only general social norms but also moral norms. However, moral norms may only be relevant to a limited range of behaviours (Norman and Conner 1996). The concept of social norms has also been further expanded to include ‘descriptive norms’ which reflect the person’s perception of whether other people carry out the behaviour (i. Anticipated regret The protection motivation theory explicitly includes a role for emotion in the form of fear. Researchers have argued that behavioural intentions may be related to anticipated emotions. For example, the intention to practise safer sex ‘I intend to use a condom’ may be predicted by the anticipated feeling ‘If I do not use a condom I will feel guilty’. Some research has shown that anticipated regret is important for predicting behavioural intentions (Richard and van der Pligt 1991). Self-identity Another variable which has been presented as a means to improve the model’s ability to predict behavioural intentions is self-identity. It has been argued that individuals will only intend to carry out a behaviour if that behaviour fits with their own image of themselves. For example, the identity ‘I am a healthy eater’ should relate to the intention to eat healthily. Further, the identity ‘I am a fit person’ should relate to the intention to carry out exercise. Some research has supported the usefulness of this variable (Sparks and Shepherd 1992). However, Norman and Conner (1996) suggested that this variable may also only have limited relevance. Ambivalence Most models contain a measure of attitude towards the behaviour which conceptual- izes individuals as holding either positive or negative views towards a given object. For example, Breckler (1994) defined it as ‘a conflict aroused by competing evaluative predispositions’ and Emmons (1996) defined it as ‘an approach – avoidance conflict – wanting but at the same time not wanting the same goal object’. A total of 325 volunteers completed a questionnaire including a measure of ambivalence assessed in terms of the mean of both positive and negative evaluations (e. This computation provides a score which reflects the balance between positive and negative feelings.

Once some diseases have been experienced discount 2mg zanaflex overnight delivery, predate modern research standards and newer they are unmistakable zanaflex 2 mg without a prescription. Also order 2mg zanaflex otc, with some the need for the Sponsor to think creatively in drugs order zanaflex 2 mg on line, the tolerability of one formulation may dif- evaluating whether or not a disease can be made fer greatly from that of another. This consideration can often be a dominant factor in determining The effects and consequences of toxicity and whether a condition is safely self-treatable. However, it is usually wise to place a time limit propensity to cause limited adverse effects). The determined by its effect on special populations, goal is to provide the lowest effective dose. It is including those patients who are particularly sen- vital to retain medically meaningful efficacy that sitive to its effects. Care should be taken to examine will provide patients with satisfying results if self- atypical patients in a study population, as well as treatment is to fulfill its proper role in the medical individual adverse reaction reports. The Sponsor must weigh safety and the Sponsor’s viewpoint tolerability against efficacy, both in the general and special populations. Failure to obtain satisfactory encountered while working as a junior hospital efficacy typically results in the patient seeking doctor. This contrasts with research on new chemi- professional advice, at which point more powerful cal entities, where the clinician generally focuses treatments can be prescribed. Typi- to the clinician for more than just straightforward cally in the prescription area, interaction with the opinions. Creativity is required and he/she has an marketing department is infrequent, although opportunity to devise concepts that are actually sometimes intense. In particular, the clinician must own brought to fruition in the form of an actual understand the needs of the brand managers and product. With makes direct judgments on the safety and market- prescription medication, one must work with what- ability of products without the intervention of a ever compounds have been previously developed regulatory agency. There is seldom which it has pre-approved in the so-called ‘mono- any input by the clinician into drugs he/she will be graph’ system. Although it is possible for the clinical has provided a series of numerous monographs, development of a new chemical entity to be poorly each one of which deals with a particular narrow handled, it is not possible for the clinical researcher therapeutic area, ranging from acne and anti- to add any characteristic that the particular chemi- helminthics to hormones and weight control. As long as a new formulation choice of compounds on which he/she and the remains within the exact requirements set forth in company will do research. This contributes in a major way to job monograph requirements are strictly met, the clin- satisfaction, but also creates the need to act with ician in charge will make the final judgment on much more speed in advancing one’s own portion whether a new formulation is satisfactory for mar- of the development efforts. This system exists only in the United States clinician to participate in every phase of early and it provides for a striking amount of speed and planning of a development program. You panies will be moving forward with similar pro- can never appreciate the value of having a regu- jects. Both commercial and personal success rely latory agency review your work and make the final upon being the first to market. Thus, the program decision to allow marketing until you do not have must be planned for success on the first try. However, and simpler for a product to remain within the with topical drugs, where irritation and allergeni- monograph requirements, every effort is made to city are a problem, the judgment of suitability for do so if it is possible. This required to those in which an extensive series of considerably speeds and simplifies the course of tests is needed before full confidence can be felt in a the research effort but again results in greater formulation. Such a survey can rapidly pro- This is the process by which a drug that has pre- vide a much more reliable database than sponta- viously been used only by prescription is converted neous reporting. Therefore, it is extremely difficult to ity of the drug, its ability to show efficacy in the estimate correct rates of occurrence of individual hands of nonprofessionals and a relative absence of adverse effects. It is possible reliance is placed solely on spontaneous reports for that a drug may simply not have had adequate collection of data. It takes time If the principal barrier to switch has been a lack to accumulate a substantial use database of real- of clinical experience with a drug, this can be world experience. This is essential to make it pos- remedied by the collection of a large adverse reac- sible to form a judgment about safety in prescrip- tion database. For drugs with 1000 sales this can point, it is almost always necessary to supplement easily take 10 years or more.

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Alcoholism was therefore seen as a behaviour that deserved punishment discount zanaflex 2mg with mastercard, not treatment; alcoholics were regarded as choosing to behave excessively buy zanaflex 2mg without a prescription. This perspective is similar to the arguments espoused by Thomas Szasz in the 1960s concerning the treatment versus punishment of mentally ill individuals and his distinction between being ‘mad’ or ‘bad’ zanaflex 2mg overnight delivery. Szasz (1961) suggested that to label someone ‘mad’ and to treat them buy zanaflex 2 mg without prescription, removed the central facet of humanity, namely personal responsibility. He suggested that holding individuals responsible for their behaviour gave them back their sense of responsibility even if this resulted in them being seen as ‘bad’. Similarly, the moral model of addictions considered alcoholics to have chosen to behave excessively and therefore deserving of punishment (acknowledging their responsibility) not treatment (denying them their responsibility). The temperance movement was developed and spread the word about the evils of drink. Alcohol was regarded as a powerful and destructive substance and alcoholics were regarded as its victims. This was the earliest form of a biomedical approach to addiction and regarded alcoholism as an illness. Alcohol was seen as an addictive substance, and alcoholics were viewed as passively succumbing to its influence. The 1st disease concept regarded the substance as the problem and called for the treatment of excessive drinkers. The twentieth century and the 2nd disease concept Attitudes towards addiction changed again at the beginning of the twentieth century. In parallel, attitudes towards human behaviour were changing and a more liberal laissez-faire attitude became dominant. The 2nd disease model of addiction was developed, which no longer saw the substance as the problem but pointed the finger at those individuals who became addicted. Within this perspective, the small minority of those who consumed alcohol to excess were seen as having a problem, but for the rest of society alcohol consumption returned to a position of an acceptable social habit. This perspective legitimized the sale of alcohol, recognized the resulting government benefits and emphasized the treatment of addicted individuals. Alcoholism was regarded as an illness developed by certain individuals who therefore needed support and treatment. The 1970s and onwards – social learning theory Over the past few years attitudes towards addictions have changed again. With the development of behaviourism, learning theory and a belief that behaviour was shaped by an interaction with both the environment and other individuals, the belief that excessive behaviour and addictions were illnesses began to be challenged. Since the 1970s, behaviours such as smoking, drinking and drug-taking have been increasingly described within the context of all other behaviours. In the same way that theories of aggression shifted from a biological cause (aggression as an instinct) to social causes (aggression as a response to the environment/upbringing), addictions were also seen as learned behaviours. Within this perspective, the term addictive behaviour replaced addictions and such behaviours were regarded as a consequence of learning processes. This shift challenged the concepts of addictions, addict, illness and disease, however the theories still emphasized treatment. Although the development of social learning theory highlighted some of the problems with the 2nd disease concept of addictions, both these perspectives still remain, and will now be examined in greater detail. The three perspectives in this category represent (1) pre-existing physical abnormalities; (2) pre-existing psychological abnormalities; and (3) acquired dependency theory. All of these have a similar model of addiction in that they: s regard addictions as discrete entities (you are either an addict or not an addict); s regard an addiction as an illness; s focus on the individual as the problem; s regard the addiction as irreversible; s emphasize treatment; s emphasize treatment through total abstinence. A pre-existing physical abnormality There are a number of perspectives which suggest that an addiction is the result of a pre-existing physical abnormality. For example, Alcoholics Anonymous argue that some individuals may have an allergy to alcohol and therefore become addicted once exposed to the substance. From this perspective comes the belief ‘one drink – a drunk’, ‘once a drunk always a drunk’ and stories of abstaining alcoholics relapsing after drinking sherry in a sherry trifle. In terms of smoking, this perspective would suggest that certain individuals are more sensitive to the effects of nicotine.

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Endotracheal intubation bypasses these normal physiological mechanisms zanaflex 2mg overnight delivery, necessitating artificial replacement purchase zanaflex 2 mg on line. Hot air transports more water vapour than cold air and so fully saturated room air/gas (100 per cent relative humidity) will not be fully saturated once warmed to body temperature order 2mg zanaflex mastercard. Gas not fully saturated absorbs moisture from airway surfaces 2 mg zanaflex with amex, causing dehydration, making mucus more viscid. Viscid mucus increases: ■ risk of chest infection ■ risk of airway encrustation/obstruction ■ airway resistance and work of breathing ■ surfactant dysfunction Gas should therefore be heated and fully saturated exogenously; tracheal gas temperature should be 32–36°C. Heated water baths provide an ideal medium for bacterial incubation, particularly pseudomonas. Water bath humidifiers may cause overhumidification, mucosal burns, hyperthermia and water intoxification (Jackson 1996). Where exogenous heat is used, temperature of inspired air should be continuously monitored. Current dilemmas between humidification and infection control lack an ideal solution. Saline lavage to remove encrusted secretions can cause various problems (discussed below). However pulmonary oedema from increased capillary permeability may limit hydration of critically ill patients. Airway management 43 Suction Intubation bypasses non-specific mucus and cilial defences, while impaired cough reflexes from critical illness, antitussives and sedation, enable accumulation of lower respiratory tract secretions, reducing/obstructing airway patency (increasing work of breathing) and providing media for bacterial growth. Endotracheal suction can remove accumulated secretions, but can also cause: ■ infection ■ trauma ■ hypoxia ■ atelectasis Post-discharge surveys consistently identify patient anxiety and discomfort from suction (e. Puntillo 1990), and so it should never be a ‘routine’ procedure (Ashurst 1997); nurses should evaluate benefits against dangers. The changes made in endotracheal suction practice in the 1980s necessitate caution when reading older literature. Indications for suction include: ■ rattling/bubbling on auscultation ■ sudden increases in airway pressure ■ audible ‘bubbling’ from the back of the throat ■ sudden hypoxia (e. Disconnecting ventilation (inevitable unless closed-circuit suction systems are used) causes arterial desaturation, especially when patients are dependent on high levels of oxygen; preoxygenating all patients (3–5 minutes of 100 per cent oxygen) minimises risks. Although intended to remove bacteria, suction catheters can introduce/displace bacteria into lower airways. Respiratory pathogens sprayed into the environment through patients’ coughing or from suction catheters can infect others (e. Gowns, gloves, masks and goggles may protect staff, but efficacy of each needs evaluation, and their use delays suction procedures. Negative (suction) pressure damages delicate tracheal epithelium, causing possible ■ haemorrhage ■ oedema ■ stenosis ■ metaplasia. Negative pressure should be sufficient to clear secretions, but low enough to minimise trauma. Suction pressures, Intensive care nursing 44 usually measured in kilopascals (kPa) but sometimes in millimetres of mercury (mmHg), should be displayed on equipment. Intermittent release of negative pressure during suctioning has no advantage (Czarnik et al. Disconnection from ventilation and negative pressure from suction can cause hypoxia through ■ removal of oxygen supply ■ removal of oxygen-rich air from airways ■ alveolar collapse. Suction passes should therefore be as brief as possible (maximum 15 seconds), with rapid reconnection of ventilation. Nurses are recommended to hold their own breath during each pass: when they need oxygen, so will their patient. Hypoxia from bronchoconstriction (sympathetic stress response) usually follows endotracheal suction. Although Wood’s review (1998) found no proven benefit to routine preoxygenation, evidence is sparse, and failure to preoxygenate is probably more dangerous than routine preoxygenation. Many ventilators include time-limited control for delivery of 100 per cent oxygen; using these prevents inadvertent delivery of toxic levels continuing after stabilisation. If FiO2 is increased manually, it should be returned to baseline levels once PaO2 is restored.

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