By F. Muntasir. California State University, San Marcos.
By utilising a form of qualitative analysis here buy discount voveran 50mg on line, this research addresses the limited voices of consumers in adherence research in the literature discount 50mg voveran otc. Qualitative data are non-numerical and are usually obtained from unstructured or semi-structured research methods (Hesse-Biber & Leavy order 50 mg voveran, 2004). Consistently, the current research involved conducting in-depth, semi-structured interviews with outpatients with schizophrenia. Interviews explored consumers’ understandings of the meanings and uses of medication, potential obstacles and incentives to adherence, useful strategies to facilitate adherence as well as other topics spontaneously raised in relation to the topic, with the ultimate aim of gaining an insight into interviewees’ lives. Analysis remained close to the data, in order to provide a rich, descriptive account of experiences. A more detailed account of the analytic procedure will be provided later in this chapter. Although some overlap with previous findings occurred, research findings added to the qualitative research in the area and helped to contextualize the ample statistical data available on adherence. The method of data collection was face-to-face, semi-structured interviews with outpatients with schizophrenia who had experiences with taking antipsychotic medications. Interviews were conducted at day centres and medication clinics in the Northern and Eastern metropolitan areas of Adelaide and at a public hospital in Northern metropolitan Adelaide. Interviews were conducted between 31/07/2008 and 25/2/2009, and varied in length from 30 minutes to approximately two hours. Qualitative interviews were initially conducted with a view to designing an intervention to assist with medication adherence, based on interviewees’ responses. Upon analysis, however, it became clear that the data did not lend themselves to a clear-cut intervention. Furthermore, data highlighted the inter-subjectivity of medication experiences amongst consumers and interviewees frequently directly opposed one generalised intervention to address adherence on these grounds. Indeed, the developers of grounded theory, Barney Glaser and Anselm Strauss, were schooled in opposing research traditions. Glaser studied in the department of sociology at Columbia University which was renowned for a reliance on quantitative methodology whereas Strauss was schooled in the Chicago tradition, which was associated with down-to-earth, qualitative research (Glaser & Strauss, 1967). In 1967, a critical point in social science history, Glaser and Strauss co-authored the book, “The Discovery of Grounded Theory: Strategies for Qualitative Research”. At the time, there was an overwhelming preoccupation with the quantitative testing of propositions derived from a few, highly abstract “grand” theories. This lead to impoverished theory, with limited relevance to any substantive content domain and compromised the scope for the emergence of new theories (Pidgeon, 1996). Glaser and Strauss’ grounded theory, thus, served at the front of the qualitative revolution (Charmaz, 2003). In their book, Glaser and Strauss challenged the dominant view that quantitative research represents the only form of systematic social scientific inquiry. More specifically, they attempted to bridge the gap between theory and empirical research; to generate theory that is relevant to research (Glaser & Strauss, 1967). In summary, through grounded theory, Glaser and Strauss proposed a radical philosophical shift, aimed at generating more local, contextual theory that would, as a consequence, be of relevance to those studied (Pidgeon, 1996). A grounded theory approach to inquiry involves intimate engagement with the data which typically results in the generation of a theory that is 68 grounded in the data. The resultant theory is inductively developed during a study and in constant interaction with the data from that study (Ezzy, 2002; Maxwell, 2005). This theory is grounded in the actual data collected, in contrast to theory that is developed conceptually and then simply tested against empirical data. It does not rely exclusively on established views or the researcher’s own perspective, as is typical of quantitative research (Maxwell, 2005). Nonetheless, it is acknowledged that the researcher enters into the process with their own, personal preconceptions and inevitably influences the data obtained through the data gathering process (i. Grounded theory draws attention to the perspectives of research participants, including their subjective accounts of social and psychological events and of associated phenomenal and social worlds (Maxwell, 2005; Pidgeon, 1996; Rubin & Rubin, 1995). The ultimate purpose of grounded theory is to develop a theory that remains close to, and illuminates, the phenomenon under investigation by studying the experience from the standpoint of those who live it (Jones, Torres & Arminio, 2006). Grounded theory was deemed a suitable approach for the current study due to its commitment to communicating the participant perspective. I believe that the consumer perspective on medication adherence provides a valuable contribution to knowledge in the area, particularly because of the complexity of medication adherence and the failure of health services to address medication adherence effectively amongst people with schizophrenia on a large scale despite the extensive research in the area. With its openness to generating theory which has not necessarily been pre-established in research, I perceived a grounded theory approach to the topic of medication adherence as potentially groundbreaking as well as valuable both in academic and practical terms, with potential clinical implications (Rubin & Rubin, 69 1995). Although the research presented was influenced by a grounded theory approach, however, the analysis did not ultimately involve theory generation as this was beyond the scope of the thesis.
This property facilitates very rapid transfer of gases discount voveran 50mg otc, vapors and other small molecules discount 50mg voveran. Drug absorption from this region is usually more rapid than from any other epithelial route of delivery order voveran 50mg otc. This rich blood supply which promotes rapid gaseous exchange is also beneficial for systemic drug delivery. Drugs absorbed from the lung pass directly to the heart avoiding first-pass metabolism in the liver, although some drugs will be subject to first-pass metabolism during absorption in the lung. These regional differences play an important role in the absorption of drugs into the systemic circulation, which is likely to occur more efficiently from the A region. Thus delivery systems designed for systemically-acting drugs should target the A region. Bronchodilator drugs act upon the smooth muscle of conducting airways and we might expect that a more central deposition of these drugs would give a greater pharmacodynamic response. Targeting locally-acting anti-inflammatory drugs is complex since there is dispute as to whether inflammation in the central airways is less or more important than that in peripheral airways. The situation is further complicated by possible redistribution of drugs within the lung, which seems likely to occur after deposition. The epithelial permeability towards hydrophilic solutes is at least 10-fold lower than that of the endothelium. The epithelium of the lung is much more permeable than that of other mucosal routes. For example, less than 3% of an oral dose of sodium cromoglycate reaches the circulation whereas more than 70% is absorbed from the lung into the bloodstream after inhalation. In the A region the tight junction gap between type-I alveolar cells is reported as 1 nm. Consequently the permeability of the paracellular route is much greater than seen with other membranes. Large molecules up to 150 kDa are reported to be absorbed to a small extent into the bloodstream after pulmonary administration. Permeability then decreases during the first few weeks of life and then shows no further age-related changes. An increase in permeability of the alveolar membrane is seen in a number of pulmonary disease states including adult respiratory distress syndrome and fibrosis. Increased permeability will be seen in association with inflammatory reactions, where there is an influx of polymorphs and other cells into the airways. Inhalation of toxicants, such as smoke and industrial dusts, is associated with increased permeability. Hyperinflation of the lung by vigorous exercise or repeatedly performing lung function tests may also lead to increased membrane permeability, possibly resulting from a disturbance of the intercellular junctions. Lipid-soluble drugs are usually absorbed transcellularly, since they partition into the lipid membranes of the epithelial cells and then diffuse through the cells, down a concentration gradient according to Fick’s Law (see Section 1. Lung absorption rate constants correlate with the lipid/buffer distribution coefficients for a number of compounds. Highly lipophilic drugs show very rapid absorption, for example morphine shows peak blood levels within 5 minutes after inhalation. Compounds which are poorly lipid-soluble may be absorbed via the paracellular route, the drug absorption rate being inversely related to their molecular size. The absorption of these hydrophilic drugs will generally be slower than that of lipophilic drugs but will still occur more rapidly than from other mucosal routes including intestinal, rectal, nasal and buccal (see Chapters 6, 7 and 9). Large molecular weight drugs may be absorbed by the process of transcytosis, in which the macromolecule is carried in vesicles from one side of a cell to the other (see Section 1. Transcytotic mechanisms occur in type-I cells for albumin and pulmonary delivered macromolecules may be transported by similar routes. The role of these mechanisms in the absorption of drugs into the bloodstream has not been quantified and for some drugs, more than one route of absorption exists. Absorption from the gastrointestinal tract may also occur, either because of direct swallowing of a portion of the inhaled dose, or because of secondary swallowing following mucociliary clearance. Many isozymes of the cytochrome P-450 family have been identified in the respiratory tract with the highest concentrations of these occurring in the nasal and smaller airways with lower levels in the trachea and main bronchi. Their distribution tends to be more widespread and their activities much higher than is seen with the P-450 systems. Locally-acting inhaled drugs may be inactivated by these enzyme systems, for example isoprenaline and rimiterol are metabolized by catechol-O-methyl transferase. The inhaled steroid beclomethasone dipropionate is hydrolysed by esterases, firstly to an active metabolite, beclomethasone monopropionate, and then to an inactive metabolite, beclomethasone. Inhaled drugs intended for systemic action are likely to be subjected to some first-pass metabolism during their absorption from the lung. The extent of this pre-systemic first-pass metabolism in the lung has not been fully quantified for many drugs but is estimated to be far less than that seen in the gastrointestinal tract and liver after oral dosing (see Section 6. A brief overview of both the advantages and disadvantages of pulmonary drug delivery is given below. Local administration is also associated with some disadvantages for these drugs: • oropharyngeal deposition may give local side-effects; • patients may have difficulty using the delivery devices correctly.
Prepare the pt by providing the information and instructions about the procedure 2 discount 50 mg voveran mastercard. Place patient in upright position on edge of bed with feet supported on stool purchase 50 mg voveran, or place in chair order voveran 50 mg overnight delivery. The physician, using aseptic technique, inserts the trocar through a puncture wound below the umbilicus. Monitor the patient closely for signs of vascular collapse: pallor, increased pulse rate, or decreased blood pressure. Continue to monitor vital signs every 15 minutes for 1 hour,every 30 minutes over 2 hours, then every hour over 2 hours and then every 4 hours. Assess for hypovolemia, electrolyte loss, changes in mental status, and encephalopathy. Provide patient education 20 Nursing Management Assessment and documentation of intake and output, abdominal girth, and daily weight to assess fluid status. The nurse monitors serum ammonia and electrolyte levels to assess electrolyte balance, response to therapy, and indicators of encephalopathy. The mortality rate resulting from the 21 first bleeding episode is 45% to 50%; it is one of the major causes of death in patients with cirrhosis Clinical Manifestations The patient with bleeding esophageal varices may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. This patient is critically ill, requiring aggressive medical care and expert nursing care, and is usually transferred to the intensive care unit for close monitoring and management. Vasopressin (Pitressin) may be the initial mode of therapy because it produces constriction of the splanchnic arterial bed and a resulting decrease in portal pressure. Somatostatin and octreotide (Sandostatin) have been reported to be more effective than vasopressin in decreasing bleeding from esophageal varices 2. In this procedure, pressure is exerted on the cardia (upper orifice of the stomach) and against the bleeding varices by a double-balloon tamponadeThe tube has four openings, each with a specific purpose: gastric aspiration, esophageal aspiration, inflation of the gastric balloon, and inflation of the esophageal balloon. Dangers and complication of tamponade balloon Displacement of the tube and the inflated balloon into the oropharynx can cause life-threatening obstruction of the airway and asphyxiation. After treatment, the patient must be observed for bleeding, perforation of the esophagus, aspiration pneumonia, and esophageal stricture. Antacids may be administered after the procedure to counteract the effects of peptic reflux. Esophageal Banding Therapy (Variceal Band Ligation) A rubber band–like ligature is slipped over an esophageal varix via an endoscope. An expandable stent is inserted and serves as an intrahepatic 25 shunt between the portal circulation and the hepatic vein, reducing portal hypertension. Complications may include bleeding, sepsis, heart failure, organ perforation, shunt thrombosis, and progressive liver failure 6. Surgical Bypass Procedures of the portal circulation can prevent variceal bleeding if the shunt remains patent. A mesocaval shunt is created by anastomosing the superior mesenteric vein to the proximal end of the vena cava or to the side of the vena cava using grafting material. The lower end of the esophagus is reached through a small gastrostomy incision; a staple gun permits anastomosis of the transected ends of the esophagus. Rebleeding is a risk, and the outcomes of these procedures vary among patient populations. Nursing Management Monitoring the patient‘s physical condition and evaluating emotional responses and cognitive status. Gastric suction usually 27 Vitamin K therapy and multiple blood transfusions often are indicated because of blood loss. Pathophysiology Ammonia accumulates because damaged liver cells fail to detoxify and convert the ammonia that is constantly entering the bloodstream to urea. The patient appears slightly confused, has alterations in mood, becomes unkempt, and has altered sleep patterns. The patient tends to sleep during the day and have restlessness and insomnia at night. A handwriting or drawing sample (eg, star figure), taken daily, may provide graphic evidence of progression or reversal of hepatic encephalopathy. The odor has also been described as similar to that of freshly mowed grass, acetone, or old wine. Approximately 35% of all patients with cirrhosis of the liver die in hepatic coma. Medical Management Lactulose (Cephulac) is administered to reduce serum ammonia levels. It acts by several mechanisms that promote the excretion of ammonia in the stool: (1) ammonia is kept in the ionized state, resulting in a fall in colon pH, reversing the normal passage of ammonia from the colon to the blood; (2) evacuation of the bowel takes place, which decreases the ammonia to which decreases the ammonia absorbed from the colon. Additional principles of management of hepatic encephalopathy include the following: 1. A daily record is kept of handwriting and performance in arithmetic to monitor mental status. Potential sites of infection (peritoneum, lungs) are assessed frequently, and abnormal findings are reported promptly. Protein intake is restricted in patients who are comatose or who have encephalopathy that is refractory to lactulose and antibiotic therapy 8.
The more familiar you are with your own mind generic voveran 50 mg amex, the easier it will be for you to intervene in your stress responses buy generic voveran 50 mg. Now that you’re getting a bit more familiar with your own mind cheap voveran 50mg with mastercard, let’s try a few more experiments. If a different thought arises, other than mentally watching your breath-cycles and counting them, then start right back at the beginning at one. It’s important that you really try to do all of the experiments and practice suggestions in this book. Give this breath exercise a try right now and then return to the book when you’re through. Sometimes I can’t get beyond one or two breath-cycles before another thought pops up! Your mind is constantly thinking and as amazing as it is, you probably can’t even maintain your concentration for ten breaths. It can be very difficult for you to develop the concentration to be mentally present and fully aware of what’s going on in the here and now. Your mind is like a little hummingbird, flitting from one sensation, thought or perception to the next. Your thoughts are very powerful and can easily pull you away from what you’re doing. You can get carried away into your various mental worlds at the drop of a hat, which leads us to the next concept. As it turns out, both Eastern and Western observations confirm that we all have the ability to focus attention on what’s happening in the present moment, right in the here and now, and that when we do so, it silences and calms the mind. Even if you only manage this present-focus for a short period of time, what time you do spend in the present, is time that takes away from the habitual thoughts of the past or future. Contemplating the past and the future also just happens to be where most of your stressful thoughts arise. You probably worry most about either what’s going to happen or what has already happened. What’s happening right now, in this very instant, is likely considerably less stressful. Let’s try an experiment to see if you can bring those pesky, flitting little hummingbird-thoughts back into the present. Close your eyes tightly and bring all of your focus to the sensation of tension around your eyes. Squeeze your eyes even more tightly closed and feel which of your muscles are tightening in your face, between your eyes and in your forehead. Give this exercise a try right now and then return to the book when you’re through. H 16 • Mindfulness Medication Try it again and really focus on scrunching your eyes closed and feeling the tension in your eyes as well as around them. When you fix your concentration on doing something like this, I think you’ll find that it pushes any other thoughts of yesterday or tomorrow right out of your mind. Is it skiing, dancing, cooking, painting, gardening, photography or playing hockey? At those times when you’re deeply engrossed in a favourite activity does time stand still, or do other thoughts come into your consciousness? When you’re totally present in what you are doing, the only thoughts that exist tend to be about the activity you are engaged in. You already have the ability to quiet your mind and make it focus and that just happens to be a characteristic of the human mind that you can put to use for reducing your stress. I know what you’re saying is probably something like, “So scrunching my eyes reduces stress? As you’ve no doubt noticed during the preceding exercises, thoughts come and go very frequently. Most of us normally do not have the ability to consistently maintain concentration on one thought. Even if you’re generally feeling sad, angry, or happy, within a short time your mind will still drift from thought to thought. If each thought is that important and meaningful why don’t thoughts stay around longer than they do? The tricky thing about any thought is that while you find yourself immersed in it, it feels permanent. However, if you wait it out, often just a little longer, that thought will actually pass and then you’ll have, at least temporarily, a break from it. If you can think of your thoughts as clouds that form and change, vanish and reform, rather than as things that are true, absolute and permanent, it may help you to de-stress. A lot of what you’re thinking Meet Your Mind • 17 when you’re stressed is just a string of hypothetical ‘what-ifs’. When you bring some awareness to a particularly stressful moment, you can let the natural inclination of the mind to move on, work to your advantage.