This is called presystemic (or ‘first-pass’) panies can manufacture and market the product purchase 120 ml liv 52 with amex, sometimes metabolism buy 120 ml liv 52 fast delivery. At this time buy cheap liv 52 200 ml, pharmacists usually shop • ‘Bioavailability’ describes the completeness of around for the best buy discount liv 52 60 ml visa. If a hospital doctor prescribes by propri- absorption into the systemic circulation. The amount of etary name, the same drug produced by another company may drug absorbed is determined by measuring the plasma be substituted. The for- bioavailability implies that no drug enters the systemic mulation of a drug (i. This is a particular concern with slow-release or drugs and different pharmaceutical formulations of the sustained-release preparations, or preparations to be adminis- same drug, but also from one individual to another, tered by different routes. Drug regulatory bodies have strict cri- depending on factors such as dose, whether the dose teria to assess whether such products can be licensed without is taken on an empty stomach, and the presence of gastro-intestinal disease, or other drugs. The rate at which a drug enters the body determines for another may give rise to clinical problems unless the the onset of its pharmacological action, and also influences the preparations are ‘bioequivalent’. Regulatory authorities intensity and sometimes the duration of its action, and is therefore require evidence of bioequivalence before important in addition to the completeness of absorption. They provide an approach to improving (brand named or generic) are sufficiently similar for their sub- absorption and distribution. If evidence is presented that a new One approach to improving absorption or distribution to a rel- generic product can be treated as therapeutically equivalent to atively inaccessible tissue (e. This does not imply that all possible pharmacokinetic absorbed and from which active drug is liberated after absorp- parameters are identical between the two products, but that tion. There are two main mechanisms of Oral drug administration may be used to produce local effects drug absorption by the gut (Figure 4. Non-polar lipid-soluble dependent acrylic coat that degrades at alkaline pH as in the agents are well absorbed from the gut, mainly from the small intestine, because of the enormous absorptive surface area provided by villi and microvilli. Naturally occurring polar substances, including sugars, amino acids and vitamins, are Relatively well- Relatively poorly absorbed and/or absorbed and/or absorbed by active or facilitated transport mechanisms. Drugs good tissue poor tissue that are analogues of such molecules compete with them for penetration penetration transport via the carrier. The following advantages have been claimed for the rec- tal route of administration of systemically active drugs: Prolonged action and sustained-release preparations 1. Exposure to the acidity of the gastric juice and to digestive Some drugs with short elimination half-lives need to be adminis- enzymes is avoided. The portal circulation is partly bypassed, reducing ence to the prescribed regimen difficult for the patient. The aim of such Rectal diazepam is useful for controlling status epilepticus in sustained-release preparations is to release a steady ‘infusion’ of children. Metronidazole is well absorbed when administered drug into the gut lumen for absorption during transit through rectally, and is less expensive than intravenous preparations. Reduced dosing frequency may improve However, there are usually more reliable alternatives, and compliance and, in the case of some drugs (e. Other limitations of slow-release preparations are: Drugs are applied topically to treat skin disease (Chapter 51). Transit time through the small intestine is about six hours, Systemic absorption via the skin can cause undesirable effects, so once daily dosing may lead to unacceptably low trough for example in the case of potent glucocorticoids, but the concentrations. If the gut lumen is narrowed or intestinal transit is slow, temic therapeutic effect (e. Osmosin™, an osmotically released formulation of Factors affecting percutaneous drug absorption include: indometacin, had to be withdrawn because it caused 1. Plastic-film occlusion (sometimes employed by dermatologists) increases hydration. The Sublingual administration has distinct advantages over oral physical chemistry of these mixtures may be very complex administration (i. Glyceryl trinitrate, buprenorphine and fentanyl are enhances absorption, and solutions penetrate best of all; given sublingually for this reason. Sublingual adminis- important when treating infants who have a relatively tration provides short-term effects which can be terminated by large surface area to volume ratio.
Descriptions of Being discount liv 52 200 ml mastercard, of whose thought the universe in eternity is wounded men order liv 52 120 ml with visa, disease cheap liv 52 200 ml free shipping, and illness abounded order liv 52 60 ml with mastercard. The French Dossey (1998) recasts Nightingale in the mode of had the Sisters of Charity to care for their sick “religious mystic. For Nightingale, service to God was Lord Herbert of Lea, who was the husband of service to humanity (Calabria & Macrae, 1994, p. Herbert had an innovative solution: appoint Miss In Nightingale’s view, nursing should be a search Nightingale and charge her to head a contingent of for the truth; it should be a discovery of God’s laws nurses to the Crimea to provide help and organiza- of healing and their proper application. It was what she was referring to in Notes on Nursing when a brave move on the part of Herbert. Medicine and she wrote about the Laws of Health, as yet uniden- war were exclusively male domains. It was the Crimean War that provided the woman into these hitherto uncharted waters was stage for her to actualize these foundational beliefs, risky at best. But, as is well known, Nightingale was rooting forever in her mind certain “truths. It was in the Barracks Hospital of Scutari questing her to accept this post, Herbert wrote: that Nightingale acted justly and responded to a call for nursing from the prolonged cries of the Your own personal qualities, your knowledge and your power of administration, and among greater British soldiers (Boykin and Dunphy, 2002, p. Accompanied by 38 handpicked “nurses” —Nightingale, cited in Woodham-Smith (1983) who had no formal training, she arrived on November 4, 1854, to “take charge” and did not re- Nightingale had powerful friends and had turn to England until August 1856. When Great own correspondence, as cited in a number of Britain became involved in the Crimean War in sources (Cook, 1913; Huxley, 1975; Goldie, 1987; 1854, Nightingale was ensconced in her first official Summers, 1988; Vicinus & Nergaard, 1990), paint nursing post at 1 Harley Street. Designed by Manuel Lopez Parras in Elspeth Huxley, Florence Nightingale (1975), p. Nightingale sustained there, experiences that ce- There were no pillows, no blankets; the men lay, with mented her views on disease and contagion, as well their heads on their boots, wrapped in the blanket or as her commitment to an environmental approach greatcoat stiff with blood and filth which had been their sole covering for more than a week. The men in the corri- than 1000 men suffering from acute diarrhea and dors lay on unwashed floors crawling with vermin. In this filth lay the men’s food—Miss Nightingale saw the skinned carcass of a sheep lie in a wardallnight... Nightingale’s reply: “The strongest will be wanted at the wash tub” (Cook, 1913; Dolan, 1971). Although the bulk of this work continued to be cleansed sewers, limewashed walls, tore out shelves done by orderlies after Nightingale’s arrival (with that harbored rats, and got rid of vermin. The com- the laundry farmed out to the soldiers’ wives), it mission, Nightingale said,“saved the British Army. Because no antidote to infection existed at this Her spirituality involved the sense of a presence time, the provision—by Nightingale and her higher than human presence, the divine intelli- nurses—of cleanliness, order, encouragement to gence that creates, sustains, and organizes the uni- eat, feeding, clean bed linen, clean bodies, and clean verse, and an awareness of our inner connection to wards, was essential to recovery (Summers, 1988). Through this inner connection Mortality rates at the Barrack Hospital in flows creative endeavors and insight, a sense of pur- Scutari fell. For Miss Nightingale, spiritual- the prime minister had sent to the Crimea a sani- ity was intrinsic to human nature and was the tary commission to investigate the high mortality deepest, most potent resource for healing. Beginning their work in March, they de- Nightingale was to write in Suggestions for Thought scribed the conditions at the Barrack Hospital as (Calabria & Macrae, 1994, p. The commission cleared “556 handcarts and ness to unity with the divine was an evolutionary large baskets full of rubbish... There were four miles of beds in the Barrack Hospital at Scutari, a suburb of Constantinople. A letter to the London Times dated February 24, 1855, reported the following: When all the medical officers have retired for the night and silence and darkness have settled upon those miles of prostrate sick, she may be observed, alone with a little lamp in her hand, making her Image rights unavailable. In April 1855, after having been in Scutari for six months, Florence wrote to her mother, “[A]m in sympathy with God, fulfilling the purpose I came into the world for” (Woodham-Smith, 1983, p. Henry Wadsworth Longfellow authored “Santa Filomena” to commemorate Miss Nightingale.
There is an ever nursing discount 120 ml liv 52 amex, searching for meaning in life trusted liv 52 120 ml, and finding greater concentration of economic and political new meaning in the complexities of work itself buy cheap liv 52 60 ml line. Identifying professional nurse caring work as woven into the social and economic fabric of na- having value and an expression of one’s soul or tions quality 200 ml liv 52. As organizations were affected by issues one’s creative self at work replaces the notion of of cost and profit, health-care systems underwent nursing as performing machinelike tasks. Leadership models, which ings and symbols of organizations (Ray, 1981, are fundamentally hierarchical because of the need 1989). Weber (1999) actually predicted that the fu- for order, continue to head the short-lived partici- ture belonged to the bureaucracy and not to the pative movement toward decentralization. Weber, who saw bureaucracy as an still in the hands of a few as global economics and efficient and superior form of organizational the market rule (Korten, 1995). As a result, the con- arrangement, predicted that bureaucratization of cept of bureaucracy does not seem as bad as was enterprise would dominate the world (Bell, 1974; once thought. This, of course, is witnessed by the radical than the business paradigm that focuses on current globalization of commerce. Recent acquisi- competition and response to market forces, subse- tions and mergers of industrial firms and even quently eradicating standards of fairness for health-care systems, especially in the United States, human beings in the workplace. As such, caring is considered by of organization, Britain and Cohen (1980) stated many nurse scholars to be the essence of nursing that, “Like it or not, humankind is being driven to (Boykin & Schoenhofer, 2001; Leininger, 1981, a bureaucratized world whose forms and functions, 1991, 1997; Morse, Solberg, Neander, Bottorff, & whose authority and power must be understood if Johnson, 1990; Ray, 1989, 1994a, 1994b; Swanson, they are ever to be even partially controlled”(p. Although not uni- The characteristics of bureaucracies are as formly accepted, Newman, Sime, and Corcoran- follows: Perry (1991; Newman, 1992) characterized the social mandate of the discipline of nursing as • A division of labor caring in the human health experience. Caring thus • A hierarchy of offices is an influential concept, and the expression “car- • A set of general rules that govern performances ing”in the human health experience emphasizes the • A separation of the personal from the official social mandate to which nursing has responded • A selection of personnel on the basis of techni- throughout its history and encompasses the scope cal qualifications of the discipline (Roach, 2002). Caring, however, is • Equal treatment of all employees or standards of manifested in different and complex ways in the fairness nursing discipline and profession (Morse et al. Various paradigms that en- • Protection of dismissal by tenure (Eisenberg & fold the care and caring ideal exist in nursing. In the past two decades, there has been a call person, society, environment, and health character- for decentralization and the “flattening” of organi- ize the nature of nursing. The simultaneity para- zational structures—to become less bureaucratic digm illuminates the human-environment integral and more participative or heterarchical (O’Grady & nature of nursing. Many firms have begun to hold to paradigm states that what constitutes nursing’s new principles that honor creativity and imagina- reality is the view that the human being is unitary tion (Morgan, 1997). Even nursing has advanced in and evolving as a self-organizing field embedded in a more collaborative or decentralized manner by its a larger self-organizing field identified by pattern focus on patient-centered nursing and more decen- and interaction with the larger whole. Health is tralized control from administration (Long, 2003; considered expanded consciousness, and caring in Nyberg, 1998). Technological/ Although the model demonstrates that the di- Political Physiological mensions are equal, the research revealed that the economic, political, technical, and legal dimensions Legal were dominant in relation to the social and ethi- cal/spiritual dimensions. Interactions and symbolic systems of meaning are formed and reproduced from the constructions or dominant values held within discipline (Newman, 1986, 1992; Newman, Sime, & the organization. Many caring theories corre- ganization,” which is analogous to Wittgenstein’s spond to one or all of these paradigms (Morse et al. The Theory of Bureaucratic Caring has its The theory has been embraced by educators, re- roots in all these paradigms by its synthesis of car- searchers, nursing administrators, and clinicians ing and the organizational context (see Figure who, after witnessing changes in health-care policy 23–1). In the qualitative study of as a foundation for additional research studies of caring in the institutional context, the research the nurse-patient relationship (Ray, 1987; Turkel, revealed that nurses and other professionals strug- 1997; Turkel & Ray, 2000, 2001). The discovery of bureaucratic car- Practice Theory Reviewed: ing resulted in both substantive and formal theories (Ray, 1981, 1984, 1989). The substantive theory Evolution of Theory emerged as differential caring and showed that Development caring in the complex organization of the hospital was complicated and differentiated itself in terms Facing the challenge of the crisis in health care and of meaning by its context—dominant caring di- nursing, disillusionment of registered nurses about mensions related to areas of practice or units the disregard for their caring services, and the con- wherein professionals worked and clients resided. The laws of haunted by bureaucracies, some functional, many the dialectic—codetermination of polar opposites, problematic. What, then, is the deeper reality of negation of each of the separate codetermining op- nursing practice? The following is a presentation of posites, and synthesis of conceptualizations toward theoretical views that relate to bureaucratic caring transformation and change—demonstrated that theory, culminating in a vision for understanding the understanding of institutional caring as a the deeper significance of nursing life. Substantive and formal theories emerge from in-depth qualitative studies of social cultural Middle-range theory deals with a relatively broad processes—action and interaction associated with scope of phenomena but does not cover the full the social world. The researcher considers evidence range of phenomena of a discipline, as do grand about how one event affects another and explains theories that encompass the fullest range or the the things observed and recorded by developing most global phenomena in the discipline (Chinn & theoretical relationships about the data.
Parsons & Shils liv 52 200 ml without prescription, 1951; Rapoport buy 200 ml liv 52, 1968; and Von We define the person (behavioral system) as being Bertalanffy buy cheap liv 52 100 ml, 1968) were all sources for her model liv 52 120 ml with amex. In homeorrhesis, the system stabi- the sustenal imperatives (Grubbs, 1980; Holaday, lizes around a trajectory rather than a set point. A toddler placed in a body cast may show motor lags when the cast is removed but soon shows age- Wholeness and Order appropriate motor skills. An adult newly diagnosed The developmental analogy of wholeness and order with asthma who does not receive proper education is continuity and identity. Given the behavioral sys- until a year after diagnosis can successfully incor- tem’s potential for plasticity, a basic feature of the porate the material into her daily activities. These system is that both continuity and change can exist are examples of homeorhetic processes or self- across the life span. Instead, the issue should be cast in with illness, he or she is subject to biopsychosocial terms of determining patterns of interactions perturbations. The nurse, according to Johnson among levels of the behavioral system that may (1980, 1990), acts as the external regulator and promote continuity for a particular subsystem at a monitors patient response, looking for successful given point in time. If behavioral system balance tinuity is in the relationship of the parts rather than returns, there is no need for intervention. Johnson (1990) noted that at nurse intervenes to help the patient restore behav- the psychological level, attachment (affiliative) and ioral system balance. It is hoped that the patient dependency are examples of important specific be- matures and with additional hospitalizations the haviors that change over time while the representa- previous patterns of response have been assimilated tion (meaning) may remain the same. Adaptation is defined as balance, this pattern of dependence to independ- change that permits the behavioral system to main- ence may be repeated as the behavioral system en- tain its set points best in new situations. To the ex- gages in new situations during the course of a tent that the behavioral system cannot assimilate lifetime. The nurse acts to provide con- respond to contextual changes by either a homeo- ditions or resources essential to help the accommo- static or homeorhetic process. Systems have a set dation process, may impose regulatory or control point (like a thermostat) that they try to maintain mechanisms to stimulate or reinforce certain be- by altering internal conditions to compensate for haviors, or may attempt to repair structural com- changes in external conditions. A behavioral system is embedded in an tion of ability or effort are behavioral homeostatic environment, but it is capable of operating inde- processes we use to interpret activities so they are pendently of environmental constraints through the consistent with our mental organization. Hierarchic Interaction The combination of systems theory and develop- Each behavioral system exists in a context of hier- ment identifies “nursing’s unique social mission archical relationships and environmental relation- and our special realm of original responsibility in ships. Hierarchies, or a pattern of Next, we review the model as a behavioral system relying on particular subsystems, lead to a degree of within an environment. A disruption or failure will not destroy the Person whole system but leads instead to a decomposition to the next level of stability. Johnson conceptualized a nursing client as a behav- The judgment that a discontinuity has occurred ioral system. The behavioral system is orderly, is typically based on a lack of correlation between repetitive, and organized with interrelated and in- assessments at two points of time. For example, terdependent biological and behavioral subsys- one’s lifestyle prior to surgery is not a good fit post- tems. These discontinuities can provide op- subsystems that interrelate to form the behavioral portunities for reorganization and development. Dialectical Contradiction The client is seen as a collection of behav- ioral subsystems that interrelate to form The last core principle is the motivational force for the behavioral system. Johnson (1980) described these as drives and noted that these responses are devel- oped and modified over time through maturation, system. A person’s activities in the plex, overt actions or responses to a variety of stim- environment lead to knowledge and development. Behavioral system balance is restored and a new level of development The parts of the behavioral system are called sub- is attained.