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Help client understand that he or she uses this behavior in or- der to try to increase own self-esteem order levitra professional 20mg otc impotence by smoking. If client chooses to suppress tics in the presence of others generic 20mg levitra professional overnight delivery drugs used for erectile dysfunction, provide a speciﬁed “tic time cheap levitra professional 20 mg with amex erectile dysfunction gluten,” during which client “vents” tics, feelings, and behaviors (alone or with staff). Allows for release of tics and assists in sense of control and manage- ment of symptoms. One-to-one time gives nurse the opportu- nity to provide client with information about the illness and healthy ways to manage it. Exploring feelings about the illness helps client incorporate the illness into a healthy sense of self. The results of studies indicate that a greater number of children with relatives who manifest anxiety problems develop anxiety disorders themselves than do children with no such family patterns. Studies have shown that differences in temperamental characteristics at birth may be correlated to the acquisition of fear and anxiety disorders in child- hood. This may denote an inherited vulnerability or pre- disposition toward developing these disorders. Studies indicate that children who are predisposed to anxiety disorders may be affected signiﬁcantly by stressful life events. Several theories exist that relate the development of separation anxiety to the following dynamics within the family: ✈ An overattachment to the mother (primary caregiver) ✈ Separation conﬂicts between parent and child Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence ● 49 ✈ Enmeshment of members within a family ✈ Overprotection of the child by the parents ✈ Transfer of parents’ fears and anxieties to the children through role modeling Symptomatology (Subjective and Objective Data) Symptoms of separation anxiety disorder include the following: 1. In most cases the child has difﬁculty separating from the mother, although occasionally the separation reluctance is directed toward the father, siblings, or other signiﬁcant indi- vidual to whom the child is attached. Anticipation of separation may result in tantrums, crying, screaming, complaints of physical problems, and clinging behaviors. Younger children may “shadow” or follow around the person from whom they are afraid to be separated. During middle childhood or adolescence he or she may re- fuse to sleep away from home (e. Worrying is common and relates to the possibility of harm coming to self or to the attachment ﬁgure. Depressed mood is frequently present and often precedes the onset of the anxiety symptoms, which commonly occur fol- lowing a major stressor. Common Nursing Diagnoses and Interventions for the Client with Separation Anxiety Disorder (Interventions are applicable to various health care settings, such as in- patient and partial hospitalization, community outpatient clinic, home health, and private practice. It is an alerting signal that warns of impend- ing danger and enables the individual to take measures to deal with threat. Long-term Goal Client will maintain anxiety at no higher than moderate level in the face of events that formerly have precipitated panic. Trust and unconditional acceptance are neces- sary for satisfactory nurse–client relationship. Calmness is important because anxiety is easily transmitted from one person to another. Some parents may have an underly- ing fear of separation from child, of which they are un- aware and which they are unconsciously transferring to child. Parents may be so frustrated with child’s clinging and demanding behaviors that assistance with problem solving may be required. Give, and encourage parents to give, positive reinforcement for desired behaviors. Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence ● 51 Outcome Criteria 1. Client maintains anxiety at moderate level when separation occurs or is anticipated. Long-term Goal Client will demonstrate use of more adaptive coping strategies (than physical symptoms) in response to stressful situations. Encourage child or adolescent to discuss speciﬁc situations in life that produce the most distress and describe his or her response to these situations. Client and family may be unaware of the correlation between stressful situations and the exacerbation of physical symptoms. Help child or adolescent who is perfectionistic to recognize that self-expectations may be unrealistic. Connect times of unmet self-expectations to the exacerbation of physical symptoms. Practice fa- cilitates the use of the desired behavior when individual is actually faced with the stressful situation. Client and family verbalize the correlation between separa- tion anxiety and somatic symptoms. Client verbalizes the correlation between unmet self- expectations and somatic symptoms. Long-term Goal Client will be able to spend time with others (without presence of attachment ﬁgure) without excessive anxiety. Convey to the child the acceptability of his or her not par- ticipating in group in the beginning. Gradually encourage small contributions until client is able to participate more fully. Small successes will gradually increase self-conﬁdence and decrease self-consciousness, so that client will feel less anxious in the group situation. Simple, realistic goals provide opportunities for success that increase self-conﬁdence and may encourage client to attempt more difﬁcult objectives in the future. Client is able to interact with others away from the attach- ment ﬁgure without excessive anxiety. The symptoms of delirium usually begin quite abruptly, and the duration is usually brief (e. If the underly- ing condition persists, the delirium may gradually shift to the syndrome of dementia or progress to coma. Certain medical conditions, such as systemic infections, metabolic disorders, ﬂuid and electrolyte imbalances, liver or kidney disease, thiamine deﬁciency, postoperative states, hyperten- sive encephalopathy, postictal states, and sequelae of head trauma, can cause the symptoms of delirium. The symptoms of delirium can be induced by the exposure to a toxin or the ingestion of medications, such as anticonvulsants, neuroleptics, anx- iolytics, antidepressants, cardiovascular medications, anti- neoplastics, analgesics, antiasthmatic agents, antihistamines, antiparkinsonian drugs, corticosteroids, and gastrointestinal medications. Delirium symptoms can occur in response to taking high doses of cannabis, cocaine, hallucinogens, alcohol, anxiolytics, or narcotics. Reduction or termina- tion of long-term, high-dose use of certain substances, such as alcohol, sedatives, hypnotics, or anxiolytics, can result in withdrawal delirium symptoms. Symptoms of delir- ium may be related to more than one general medical condi- tion or to the combined effects of a general medical condition and substance use. Symptomatology (Subjective and Objective Data) The following symptoms have been identiﬁed with the syndrome of delirium: 1. Emotional instability as manifested by fear, anxiety, depression, irritability, anger, euphoria, or apathy. Autonomic manifestations, such as tachycardia, sweating, ﬂushed face, dilated pupils, and elevated blood pressure. Dementia Deﬁned “Dementia” is deﬁned by a loss of previous levels of cogni- tive, executive, and memory function in a state of full alertness (Bourgeois, Seaman, & Servis, 2008).
Thirty-one pairs of spinal nerves arise from the sides of the spinal cord and leave the cord through the intervertebral foramina (spaces) to form the peripheral nervous Chapter 15: Feeling Jumpy: The Nervous System 245 system order levitra professional 20 mg psychogenic erectile dysfunction icd-9, which we discuss in the later section “Taking Side Streets: The Peripheral Nervous System buy discount levitra professional 20 mg line male erectile dysfunction icd 9. In this section purchase levitra professional paypal erectile dysfunction age 80, we review six major divisions of the brain from the bottom up (see Figure 15-3): medulla oblongata, pons, midbrain, cerebellum, diencephalon, and cerebrum. Medulla oblongata The spinal cord meets the brain at the medulla oblongata, or brainstem, just below the right and left cerebellar hemispheres of the brain. In fact, the medulla oblongata is con- tinuous with the spinal cord at its base (inferiorly) and back (dorsally) and located anteriorly and superiorly to the pons. All the afferent and efferent tracts of the cord can be found in the brainstem as part of two bulges of white matter forming an area referred to as the pyramids. Many of the tracts cross from one side to the other at the pyramids, which explains why the right side of the brain controls the left side of the body and vice versa. Along with the pons, the medulla oblongata also forms a network of gray and white matter called the reticular formation, the upper part of the so-called extrapyramidal pathway. With its capacity to arouse the brain to wakefulness, it keeps the brain alert, directs messages in the form of impulses, monitors stimuli entering the sense recep- tors (accepting some and rejecting others it deems to be irrelevant), refines body movements, and effects higher mental processes such as attention, introspection, and reasoning. Although the cortex of the cerebrum is the actual powerhouse of thought, it must be stimulated into action by signals from the reticular formation. Nerve cells in the brainstem are grouped together to form nerve centers (nuclei) that control bodily functions, including cardiac activities, and respiration as well as reflex activities such as sneezing, coughing, vomiting, and alimentary tract movements. The medulla oblongata affects these reactions through the vagus, also referred to as cra- nial nerve X or the 10th cranial nerve. Pons The pons (literally “bridge”) does exactly as its name implies: It connects the cerebel- lum through a structure called the middle peduncle, the cerebrum by the superior peduncle, and the medulla oblongata by the inferior peduncle. It also unites the cere- bellar hemispheres, coordinates muscles on both sides of the body, controls facial muscles (including those used to chew), and regulates the first stage of respiration. Midbrain Between the pons and the diencephalon lies the mesencephalon, or midbrain. It con- tains the corpora quadrigemina, which correlates optical and tactile impulses as well as regulates muscle tone, body posture, and equilibrium through reflex centers in the superior colliculus. The inferior colliculus contains auditory reflex centers and is believed to be responsible for the detection of musical pitch. The midbrain contains Part V: Mission Control: All Systems Go 246 the cerebral aqueduct, which connects the third ventricle of the thalamus with the fourth ventricle of the medulla oblongata (see the section “Ventricles” later in this chapter for more). The red nucleus that contains fibers of the rubrospinal tract, a motor tract that acts as a relay station for impulses from the cerebellum and higher brain centers, also lies within the midbrain, constitut- ing the superior cerebellar peduncle. The second-largest divi- sion of the brain, it’s just above and overhangs the medulla oblongata and lies just beneath the rear portion of the cerebrum. The cerebellar cortex or gray matter contains Purkinje neurons with pear-shaped cell bodies, a multitude of dendrites, and a single axon. It sends impulses to the white matter of the cerebellum and to other deeper nuclei in the cerebellum, and then to the brainstem. The cerebellar cortex has parallel ridges called the folia cerebelli, which are separated by deep sulci. Diencephalon The diencephalon, a region between the mesencephalon and the cerebrum, contains separate brain structures called the thalamus, epithalamus, subthalamus, and hypothal- amus. The region where the two sides of the thalami come in contact and join forces is called the intermediate mass. The thalamus is a primitive receptive center through which the sensory impulses travel on their way to the cerebral cortex. Here, nerve fibers from the spinal cord and lower parts of the brain synapse with neurons leading to the sensory areas of the cortex of the cerebrum. The thalamus is the great integrat- ing center of the brain with the ability to correlate the impulses from tactile, pain, olfactory, and gustatory (taste) senses with motor reactions. The epithalamus contains the choroid plexus, a vascular structure that produces spinal fluid. The pineal body and olfactory centers also lie within the epithalamus, which forms the roof of the third ventricle. The subthalamus is located below the thalamus and regulates the muscles of emotional expression. The hypothalamus contains the centers for sexual reflexes; body temperature; water, carbohydrate, and fat metabolism; and emotions that affect the heartbeat and blood pressure. It also has the optic chiasm (connecting the optic nerves to the optic tract), the posterior lobe of the pituitary gland, and a funnel-shaped region called the infundibulum that forms the stalk of the pituitary gland. A thin outer layer of gray matter called the cerebral cortex features folds or convolutions called gyri; furrows and grooves are referred to as sulci, and deeper grooves are called fissures. Each hemi- sphere has a set of controls for sensory and motor activities of the body. Interestingly, it’s not just right-side/left-side controls that are reversed in the cerebrum; the upper areas of the cerebral cortex control the lower body activities while the lower areas of the cortex control upper-body activities in a reversal called “little man upside down. The corpus callosum Chapter 15: Feeling Jumpy: The Nervous System 247 physically unites the two hemispheres and is the largest and densest mass of commis- sural fibers. Different functional areas of the cerebral cortex are divided into lobes: Frontal lobe: The seat of intelligence, memory, and idea association Parietal lobe: Functions in the sensations of temperature, touch, and sense of position and movement as well as the perception of size, shape, and weight Temporal lobe: Is responsible for perception and correlation of acoustical stimuli Occipital lobe: Handles visual perception Medulla The medulla, the region interior to the cortex, is composed of white matter that con- sists of three groups of fibers. Projection fibers carry impulses afferently from the brain stem to the cortex and efferently from the cortex to the lower parts of the central nerv- ous system. Association fibers originate in the cortical cells and carry impulses to the other areas of the cortex on the same hemisphere. Ventricles The brain’s four ventricles are cavities and canals filled with cerebrospinal fluid. The lateral ventricles com- municate with the third ventricle through the foramen of Monro. The third ventricle is connected by the cerebral aqueduct to the fourth ventricle, which is continuous with the central canal of the spinal cord and contains openings to the meninges. The fourth ventricle has openings that allow fluid to enter into the subarachnoid spaces. Lining the ventricles is a thin layer of epithelial cells known as ependyma, or the ependymal layer. Along with a network of capillaries from the pia mater, the ependyma and capillaries form the choroid plexus, which is the source of cerebrospinal fluid. The choroid plexus of each lateral ventricle produces the greatest amount of fluid. Fluid formed by the choroid plexus filters out by osmosis (refer to Chapter 2) and circulates through the ventricles. Fluid is returned to the blood through the arachnoid villi, finger-like projections of the arachnoid meninx, which absorbs the fluid. Twelve pairs of cranial nerves connect to the central nervous system via the brain (as opposed to the 31 pairs that connect via the spinal cord). Check out Table 15-1 for a listing of all the nerves, and then read on for a memory tool. That’s a mouthful, but students have come up with a number of memory tools to remember them. Our favorite is: Old Opera Organs Trill Terrific Arias For Various Grand Victories About History.
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Babies who need this remedy look extremely anxious and often feel relief when carried tummy- down on someone’s arm buy levitra professional 20 mg with amex lipo 6 impotence. Combination recommendation: Cocyntal by Boiron Constipation Graphites: This remedy is indicated when large stools look like little round balls order levitra professional online impotence define. Lycopodium: A person who needs this remedy has frequent indigestion with gas and bloating order levitra professional amex erectile dysfunction treatment in thane, and many problems involving the bowels. Rubbing the abdomen or drink- ing something warm may help to relieve the constipation. Combination recommendation: Laxative Combination R68 by Reckeweg Cough and Cold Aconite napellus: This remedy is excellent at the onset of a cold, denoted by symp- toms that are intense and that come on suddenly. Exposure to cold and wind, stress, or traumatic experience may precipitate the illness. Symptoms include a dry, stuffy nose with a hot, thin discharge; tension in the chest; a scratchy throat; and choking cough. Kali bichromicum: This remedy is usually indicated for later stages of a cold with thick, stringy mucus that is difﬁcult to clear from the nose and throat. Combination recommendation: Coryzalia by Boiron Depression (It is very important to see your family doctor about this situation. Discouragement, self-reproach, humiliation, and anger can lead to feelings of emptiness and worthlessness. This symptom picture is usually accompanied by nightmares and oversleeping that ﬂuctuates with insomnia. Staphysagria: This is used for feelings of hurt, shame, resentment, and suppressed emotions that can lead to depression. If under too much pressure, they can sometimes lose their natural inhibition and ﬂy into rages or throw things. A person who needs this remedy may also have insomnia (feeling sleepy all day, but unable to sleep at night), toothaches, headaches, stomach aches, or bladder infections that are all stress related. Homeopathy | 81 Combination recommendation: There is no effective combination remedy known; use Rescue Remedy by Bach for short periods when feeling overwhelmed. Diarrhea Arsenicum album: Diarrhea accompanied by anxiety, restlessness, and exhaustion is the indication. Burning pain is felt in the digestive tract, and the person may be thirsty for frequent small sips of tea or water. Podophyllum: Profuse, watery diarrhea, typically without pain, suggests this remedy will be helpful. The stomach gurgles and grumbles before the diarrhea begins, and there is a frequent feeling of urging. Combination recommendation: Diarrhea Formula R4 by Reckeweg Ear Infections Chamomilla: A sudden intolerable outburst of pain suggests a need for this remedy. Ear pain and other symptoms are worse from heat and wind, and the cheeks (often only one) may be hot and red. Pulsatilla: This remedy is often indicated for ear infections that accompany a cold. The ear is hot and swollen, and the person feels that something is pressing out of it. Combination recommendation: Earache relief drops by Similasan Eczema Mezereum: This remedy is indicated when there are intense and itchy eruptions that start as blisters, then ooze and form thick crusts. The person who requires Mezereum is usually very anxious and has a strong craving for fat. Sulphur: This remedy is very useful for those who have repeatedly used cortisone on eczema without success. Intensely burning, itching, inﬂamed eruptions that are worse from warmth and bathing suggest a need for this remedy. Combination recommendation: Calendula Gel by Boiron Flu Gelsemium: Symptoms of fatigue and aching that come on gradually, increasing over several days, may indicate a need for this remedy. A headache may begin at the back of the neck and skull, and the person may feel chills and heat running up and down the spine. Anxiety, trembling, dizziness, perspiration, and moderate fever are other indications for Gelsemium. Use this at the ﬁrst sign of ﬂu symptoms that include fever, chills, body aches and pains, and headaches. Combination recommendation: PascoLeucyn by Pascoe Headache Belladonna: Major throbbing or pounding head pain that starts at the back of the skull or upper neck and spreads to the forehead and temple (especially on the right) may indicate a need for this remedy. Pupils may be di- lated, with sensitivity to light, and the person may either feel delirious or drowsy. Spigelia: Excruciating headaches usually present on the left side of the head, with vio- lent throbbing, or stabbing pains above or through the eyeball. The person may feel better from lying on the right side with the head supported, and keeping very still. Combination recommendation: Antimigren by Pascoe Infertility Folliculinum: Women who have challenges getting pregnant could ﬁnd success with this remedy if they have irregular menstrual cycles that are often weeks delayed, with a heavy, clotty ﬂow. Luteinum: Infertile women who need this remedy typically have either polycystic ovaries, ﬁbroids, or endometriosis and often have estrogen dominance without even knowing it. Strong indications that this remedy is appropriate are early menstruation and short cycles, which represent a possible luteal phase defect. Combination recommendation: None known Menopause Lachesis: Intense hot ﬂashes with purple-red ﬂushing, palpitations, and feelings of pressure, congestion, and constriction may indicate a need for this remedy. The unique symp- tom of this picture is loquacity (extremely talkative), with a strong tendency to feel suspicious. Sepia: This remedy can be helpful if a woman’s periods are sometimes late and scanty. It is best used from the middle to the end of menopause (12–24 months after the last Homeopathy | 83 period). The uterus feels weak and saggy, and there may be cravings for vinegar and sour foods. Women who need this remedy usually feel dragged-out and weary, emotionally distraught, and fatigued. Combination recommendation: PascoeFemin by Pascoe Sprains/Strains Arnica montana: This is the most popular remedy in homeopathic literature and is best for recent traumatic injuries. Bellis perennis: This remedy is useful for deeper tissue injuries from falls, car acci- dents, and major surgery. If Arnica has been given for an injury—especially a strain or bruise—but has not had much effect, try Bellis perennis next. Combination recommendation: Traumeel by Heel Urinary Tract Infections Berberis vulgaris: This remedy is for severe cutting or burning pain that extends to the urethral opening, which may also burn at times when there is no attempt at urina- tion. After emptying the bladder, the person feels as if some urine still remains inside. Cantharis: A strong urge to urinate accompanied by cutting pains that are felt before the urine passes is a sign that this remedy is appropriate. Some describe the cutting feeling as a scalding sensation when only a few drops of urine pass at a time. Combination recommendation: Pascosabal by Pascoe Varicose Veins Carbo vegetabilis: When varicose veins are accompanied by general poor circulation with icy coldness of the extremities, and a bruised or marbled look, use Carbo veg.
Psychologists have studied the persistence of attachment styles over time usinglongitudinal research designs—research designs in which individuals in the sample are followed and contacted over an extended period of time generic levitra professional 20 mg online erectile dysfunction treatment houston tx, often over multiple developmental stages buy levitra professional toronto erectile dysfunction premature ejaculation treatment. In their research discount levitra professional 20 mg mastercard erectile dysfunction protocol video, 60 middle-class infants who had been tested in the strange situation at 1 year of age were recontacted 20 years later and interviewed using a measure of adult attachment. Waters and colleagues found that 72% of the infants received the same secure versus insecure attachment classification in early adulthood as they had received as infants. The adults who changed categorization (usually from secure to insecure) were primarily those who had experienced traumatic events, such as the death or divorce of parents, severe illnesses (contracted by the parents or the children themselves), or physical or sexual abuse by a family member. Securely attached infants have closer, more harmonious relationship with peers, are less anxious and aggressive, and are better able to understand others‘ emotions than are  those who were categorized as insecure as infants (Lucas-Thompson & Clarke-Stewart, (2007). And securely attached adolescents also have more positive peer and romantic relationships than their less securely attached  counterparts (Carlson, Sroufe, & Egeland, 2004). Conducting longitudinal research is a very difficult task, but one that has substantial rewards. When the sample is large enough and the time frame long enough, the potential findings of such a study can provide rich and important information about how people change over time and the causes of those changes. The drawbacks of longitudinal studies include the cost and the difficulty of finding a large sample that can be tracked accurately over time and the time (many years) that it takes to get the data. In addition, because the results are delayed over an extended period, the research questions posed at the beginning of the study may become less relevant over time as the research continues. Cross-sectional research designs represent an alternative to longitudinal designs. In a cross- sectional research design, age comparisons are made between samples of different people at different ages at one  time. In one example, Jang, Livesley, and Vernon (1996) studied two groups of identical and nonidentical (fraternal) twins, one group in their 20s and the other group in their 50s, to determine the influence of genetics on personality. They found that genetics played a more significant role in the older group of twins, suggesting that genetics became more significant for personality in later adulthood. Cross-sectional studies have a major advantage in that the scientist does not have to wait for years to pass to get results. On the other hand, the interpretation of the results in a cross-sectional study is not as clear as those from a longitudinal study, in which the same individuals are studied over time. Most important, the interpretations drawn from cross-sectional studies may be confounded by cohort effects. Cohort effects refer to the possibility that differences in cognition or behavior at two points in time may be caused by differences that are unrelated to the changes in age. The differences might instead be due to environmental factors that affect an entire age group. For  instance, in the study by Jang, Livesley, and Vernon (1996) that compared younger and older twins, cohort effects Attributed to Charles Stangor Saylor. The two groups of adults necessarily grew up in different time periods, and they may have been differentially influenced by societal experiences, such as economic hardship, the presence of wars, or the introduction of new technology. As a result, it is difficult in cross-sectional studies such as this one to determine whether the differences between the groups (e. Attachment styles refer to the security of this base and more generally to the type of relationship that people, and especially children, develop with those who are important to them. Give an example of a situation in which you or someone else might show cognitive assimilation and cognitive accommodation. Consider some examples of how Piaget’s and Vygotsky’s theories of cognitive development might be used by teachers who are teaching young children. Consider the attachment styles of some of your friends in terms of their relationships with their parents and other friends. Breast-fed infants respond to olfactory cues from their own mother and unfamiliar lactating females. Exploratory behavior in the development of perceiving, acting, and the acquiring of knowledge. Systems in development: Motor skill acquisition facilitates three- dimensional object completion. Young infants’ reasoning about hidden objects: Evidence from violation-of-expectation tasks with test trials only. From infant to child: The dynamics of cognitive change in the second year of life. Transforming schools into communities of thinking and learning about serious matters. Self-recognition in young children using delayed versus live feedback: Evidence of a developmental asynchrony. The development of self-esteem vulnerabilities: Social and cognitive factors in developmental psychopathology. The influence of temperament and mothering on attachment and exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Attachment, maternal sensitivity, and infant temperament during the first year of life. Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Forecasting friendship: How marital quality, maternal mood, and attachment security are linked to children’s peer relationships. The construction of experience: A longitudinal study of representation and behavior. Summarize the physical and cognitive changes that occur for boys and girls during adolescence. Adolescence is defined as the years between the onset of puberty and the beginning of adulthood. In the past, when people were likely to marry in their early 20s or younger, this period might have lasted only 10 years or less—starting roughly between ages 12 and 13 and ending by age 20, at which time the child got a job or went to work on the family farm, married, and started his or her own family. Today, children mature more slowly, move away from home at later ages, and maintain ties with their parents longer. For instance, children may go away to college but still receive financial support from parents, and they may come home on weekends or even to live for extended time periods. Thus the period between puberty and adulthood may well last into the late 20s, merging into adulthood itself. In fact, it is appropriate now to consider the period of adolescence and that of emerging adulthood (the ages between 18 and the middle or late 20s) together. During adolescence, the child continues to grow physically, cognitively, and emotionally, changing from a child into an adult. The body grows rapidly in size and the sexual and reproductive organs become fully functional.