By P. Jaroll. Bowling Green State University. 2018.

Worksheet 6-10 Emma’s Thought on Trial Worksheet Accused thought: I’m a complete failure as a mother; my son is falling apart cheap 200 mg vantin mastercard antibiotic resistant outbreak. Defending the Thought Prosecuting the Thought My son is doing horrible in He had one bad report card cheap 100 mg vantin with visa bacteria vaginalis infection. If I were a good mother, I I wonder why the teacher didn’t contact me would have known that he before report card time. I haven’t gone on a field trip Out of 30 kids, only a few parents were able to with my son’s class because drive on field trips. Other mothers even I wish I could spend more time with my son, but volunteer in the classroom. I have been putting my job That’s not really true; when my kids really need ahead of my children. Chapter 6: Indicting and Rehabilitating Thoughts 87 Defending the Thought Prosecuting the Thought I don’t know what to do to I guess I’ll do what the teacher suggests and help him. Thought Court is one of the most effective tools for combating anxiety, depression, and other unpleasant emotions. If you have trouble with the exercise, spend more time going over the Prosecutor’s Investigative Questions in Worksheet 6-3. It also doesn’t hurt to review Chapter 5 and re-read the examples in this chapter. If you still struggle, we recom- mend you consult a mental health professional who’s proficient in cognitive therapy. After the Verdict: Replacing and Rehabilitating Your Thoughts Hopefully, the prosecution presents a convincing case against a variety of your malicious thoughts, and you begin to see that many of your thoughts are guilty of scrambling reality and causing excessive emotional distress. When criminals are convicted, society usually tries to rehabilitate them and give them a second chance. In this section, we show you how to rehabilitate your guilty thoughts, one at a time. Rehabilitating your thoughts decreases feelings of depression and anxiety because rehabili- tated thoughts are less distorted, judgmental, and critical. We call rehabilitated thoughts replacement thoughts because they replace your old malicious thoughts. The reason for forming a single replacement thought is that you can use that new thought repeatedly when- ever the old, malicious thoughts start rumbling through your mind. The new thought is a quick and easy comeback to negative, distorted, reality-scrambled thinking. You can use a number of different techniques to develop effective replacement thoughts. The strategies outlined in the following sections help you discard distortions and straighten out your thinking. With these strategies, you discover how to replace your twisted thoughts with more helpful, realistic replacement thoughts. You start by imagining that a good friend of yours is going through the same kind of problem as you are. We don’t want you to simply try to make your friend feel better by sugarcoating the issue; rather, tell your friend about a reasonable way to think about the problem. The essence of this powerful, yet surprisingly simple, technique is that the advice you would give a friend is advice you can give to yourself. The following example shows you how to use Getting Help from a Friend to your advantage. Emma (see “Emma: Filled with anxiety” earlier in this chapter) has taken her most malicious thought to Thought Court and found it guilty. She imagines Louise coming to her with the same problem and concerns about her son.

However vantin 200mg overnight delivery antibiotic types, nonurgent treatment should be deferred until the patient is able to give consent 200mg vantin amex antimicrobial agent definition. Information acquired by a medical practitioner from or about a patient in the course of his or her professional work is confidential and must never be disclosed to others without either the consent of the patient or other proper justification. Confidentiality is primarily a professional conduct matter for the medi- cal practitioner, but patients also have a legal right to confidentiality, pro- tected by law. Doctors are responsible for the safekeeping of confidential information against improper disclosure when it is stored, transmitted to others, or dis- carded. If a doctor plans to disclose information about a patient to others, he or she must first inform the patient of that intention and make clear that the patient has an opportunity to withhold permission for its disclosure. Patients’ requests for confidentiality must be respected, except for exceptional circum- stances, such as where the health or safety of others would otherwise be at serious risk. If confidential information is disclosed, the doctor should release only as much as is necessary for the purpose and must always be ready and will- ing to justify the disclosure—for example, to the relevant medical council or board or to the courts. Where confidential information is to be shared with healthcare workers or others, the doctor must ensure that they, too, respect confidentiality. Death and Confidentiality The duty of confidentiality extends beyond the death of the patient. The extent to which information may properly be disclosed after the death of a patient depends on the circumstances. In general, it is prudent to seek the Fundamental Principals 47 permission of all the personal representatives of the deceased patient’s estate, such as the executors or administrators, before any information is disclosed. A doctor with any doubt should take advice from a professional advisory organization, such as a protection or defense organization. Detention and Confidentiality A forensic physician (or equivalent) should exercise particular care over confidentiality when examining persons who are detained in custody. When taking the medical history and examining the detainee, it is common for a police or other detaining official to be in attendance, perhaps as a “chaperone” or simply as a person in attendance, nearby to overhear the conversation. Such officials will not owe to the detainee the same duty of confidentiality that is owed by a medical or nurse practitioner nor be subject to similar professional sanctions for a breach of confidentiality. The doctor called on to examine a detainee must take great care to ensure that the person being examined clearly understands the role of the forensic physician and the implications for confidentiality. The detainee must under- stand and agree to the terms of the consultation before any medical informa- tion is gathered, preferably giving written consent. The examining doctor should do everything possible to maintain the con- fidentiality of the consultation. An accused person’s right of silence, the pre- sumption of innocence, rights under human rights legislation, and so forth may produce areas of conflicting principle. The doctor’s code of professional conduct may conflict with statutory codes to which custody officials are bound (e. It may be essential to take the medical history in strict confidence, commensurate with adequate safe- guards against violent behavior by the prisoner, and insist on a neutral chaper- one for a physical examination. In the rest of this chapter, it is possible only to highlight the issues; their resolution will vary according to local rules and circumstances. In the United Kingdom, guidance for forensic physicians is available from their professional bodies (25). Exceptions to the General Duty of Confidentiality Under several circumstances the doctor may legitimately disclose infor- mation gained about a patient during his or her professional work. The Patient’s Permission The confidences are those of the patient, not those of the doctor, so if a patient requests or consents to their disclosure, the information may be per- fectly and properly disclosed within the terms of the patient’s permissions.

Gastric colonies migrating up nasogastric tubes readily cause pneumonia: uninterrupted enterai feeding increases ventilator-associated pneumonia by over 54 per cent (Lee et al purchase vantin 100 mg without a prescription bacteria resistant to penicillin. Rest periods from enteral feeds enable gastric emptying and return to below pH 3 (Rennie 1993a) generic vantin 100mg on line antibiotic resistance scientific journal. Even with reduced absorption, gastric emptying should occur within one hour; Zainal (1994) and Lee et al. Diarrhoea is an imbalance between fluid entering the colon and reabsorption, and may be caused by: ■ excessive fluid (colonic absorption is limited to about 4. Enteral feeds should not cause diarrhoea unless hyperosmolar, or volumes exceed 275 ml/hour (Adam & Osborne 1997). Nutritional assessment Nutritional needs in critical illness should be carefully assessed to prevent knee-jerk reactions. Simple measurements (anthropometry) include: ■ height ■ weight ■ mid-upper-arm circumferences (low=overall weight loss) ■ triceps skinfold thickness (low=significant loss of fat stores) ■ mid-arm muscle circumference (=protein depletion) As half the body fat stores are subcutaneous, measuring skinfold thickness (e. However gross oedema and deceptive increases in body weight may mask muscle atrophy (Sav 1997). But metabolic analysers are expensive, and inaccurate with high oxygen concentrations, acidosis and haemofiltration (Adam & Osborne 1997). Plasma albumin indicates protein synthesis (Say 1997), but hypoalbuminaemia in critically ill patients is multifactorial. Periodic urinalysis is cheap, simple and quick, and so although the causes of abnormalities may be unclear, it provides a means both to detect problems and monitor progress. Implications for practice ■ nutrition benefits from multidisciplinary team approaches; bedside nurses can usefully coordinate care ■ enterai feeding is usually preferable ■ if nasogastric feeding fails, lower gastrointestinal tubes should be considered ■ feed regimes should be individually assessed ■ feed regimes should be fully completed, benefits (and problems) being monitored ■ diarrhoea is rarely caused by nasogastric feeding, so is not an indication to stop feeds Summary Feeding critically ill patients remains problematic, yet it is fundamental to their recovery. Nutritional needs and benefits are often less obvious than those of other major systems, but this chapter has included various noninvasive ways to assess nutritional needs. Further reading Although much is written on nutrition, material does date quickly. Verity (1996b) and Say (1997) offer more recent nursing perspectives, while Schears and Deutschman (1997) is a comprehensive medical article. Methany (1993) presents a rigorous literature review of nasogastric Intensive care nursing 86 nutrition; Kennedy (1997) contains useful material on enterai feeding, although does overstate some aspects. Clinical scenario Sally Day is 35 years old, weighs approximately 60 kg, with an arm span of 1. Her injuries include fractures to lower ribs, pulmonary contusions, and she has a high index of suspicion for damaged spleen. In order to reduce any inter-abdominal pressure on her potentially injured spleen, Sally’s stomach was carefully emptied (decompression of stomach). How can the risks be minimised and Sally’s energy requirements met (in relation to her injuries, fluid management, and metabolic response to injury and starvation). What does exist is largely anecdotal residue from rituals (Hatton- Smith 1994); much research uses inadequate sample sizes: De Walt and Haines’ much- cited 1969 study used one adult (Kite & Pearson 1995), while Nelsey’s (1986) sample size was four patients, one being used for control. The mouth is used to communicate (lip-reading is possible despite intubation, and following extubation, oral discomfort may make speech difficult). The mouth is also associated with intimate emotions (smiling, kissing); patients with, or thinking they have, dirty mouths or halitosis may feel psychologically isolated. Mouthcare should therefore Intensive care nursing 88 ■ maintain hygiene ■ keep the oral cavity moist ■ promote comfort ■ protect from infection ■ prevent trauma ■ prevent dental decay. Oral anatomy is briefly revised, but readers should supplement any aspects they are not familiar with from anatomy texts. Anatomy Unlike all other major body systems, gut stimulation is counterproductive to ‘fight or flight’ responses: parasympathetic nerve stimulation accelerates gut functions, while sympathetic nerve stimulation decelerates them. Placing cotton wool rolls on the main salivary glands can remove excess saliva as effectively (and with less trauma) as endotracheal suction.

Training proce- ‘core audit elements’ and ‘enriched’ by additional dures and documentation for monitors should be elements to form a systems audit buy cheap vantin 100mg online antibiotic resistance animal agriculture. The following paragraphs This includes the review of activities such as co- describe selected systems audit; further informa- monitoring or supervised visits trusted vantin 100mg treatment for uti in hospital. Doc- the very limited information on the drug’s toxico- umentation of monitoring visits is essential, and logical and pharmacological effects on one hand the audit should therefore evaluate the contents of and the importance of the trials to the entire drug monitoring reports and their timely preparation development program on the other hand, audits of and also check if contacts with the investigator such trials are a valuable component of the audit sites between monitoring visits are adequate program. Such systems audits tion (or alternative documentation for systems are performed across functional boundaries. Such which have been in place for a long time and are systems audit can be combined with a database not validated according to current requirements) audit and/or an audit of the final study report. System documentation, instruction manuals in data management, for statistical analyses and and appropriate training records for anybody report generation is fully validated and validation involved in computer systems (either as developer is adequately documented. All programs written, hardware and software should be checked during including database set up and statistical analyses the audit. Conclusions drawn in the final study report must be valid and substantiated by clinical data included in the Investigational medicinal products report. Finally, account- individual involved in conducting a trial should be ability and reconciliation information for the qualified by education, training and experience to study medication should be consistently performed perform his or her respective task(s)’. For each employee in clinical drug development, training Pharmacovigilance/safety reporting records should be available to document the train- ing and demonstrate the qualification and experi- Pharmacovigilance is a key area in clinical devel- ence. Training files should be archived when opment, and information on adverse events experi- employees leave the company. The training records enced in clinical trials and after the drug has been should also include a current job description and launched must be reliably handled and reported previous versions should be retained. Attendance at internal panies must have a clearly defined pharmacovigi- and external training courses and conferences/ lance system established even before they have a meetings should be documented. Ideally, training product in the market and are still in the drug programs are outlined for induction and continual development phase to be able to make proper training. A dedicated person (and The audit should also verify procedures in those a backup) must be responsible for the management functional areas which provide services to the and operation of the archive. A reasonable timeframe should be specified the capability of an external provider, such audits for documentation to be moved into the archive can also be conducted to verify compliance after trial termination. To ensure Refrigerators/freezers/cold rooms must be tem- that they are capable of providing the services in a perature-monitored, connected to an alarm system, reliable manner and to the standards expected in be maintained, cleaned and calibrated as required. Accessed January 1, variety of functional areas and cross-functional, to 2006, at http://pharmacos. Auditors should be able to deal with con- Validation in Clinical Research – a Practical Guide. AccessedFebruary1,2006,athttp:// assessments and contribution to inspection readi- www. European Commission, Volume 4, Good Manufacturing References Practices, Annex 13 Manufacture of Investigational Medicinal Products, July 2003. Medical experiments in non-patient volunteer Expert Group of the German Society for Good Research studies. Accessed January 1, 2006, at onmental Management Systems Auditing, 3 October http://www. Quality Management Systems – Fun- Sponsors, Contract Research Organizations and damentals and Vocabulary, 20 September 2005. Effective and practical risk man- Characterized, Therapeutic, Biotechnology-derived agement options for computerised systems valida- Products, November 1995. Accessed Assembly, Edinburgh, Scotland, 2000, with Note February 1, 2006, at http://www.