Metabolic rate theory The body uses energy for exercise and physical activity and to carry out all the chemical and biological processes that are essential to being alive (e order lozol 2.5mg line. The rate of this energy use is called the ‘resting metabolic rate’ cheap 2.5mg lozol fast delivery, which has been found to be highly heritable (Bouchard et al. It has been argued that lower metabolic rates may be associated with obesity as people with lower metabolic rates burn up less calories when they are resting and therefore require less food intake to carry on living. A group in Phoenix assessed the metabolic rates of 126 Pima Indians by monitoring their breathing for a 40-minute period. The study was carried out using Pima Indians because they have an abnormally high rate of obesity (about 80–85 per cent) and were considered an interesting population. The subjects remained still and the levels of oxygen consumed and carbon dioxide produced was measured. The researchers then followed any changes in weight and metabolic rate for a four-year period and found that the people who gained a substantial amount of weight were the ones with the lowest metabolic rates at the beginning of the study. In a further study, 95 subjects spent 24 hours in a respiratory chamber and the amount of energy used was measured. The subjects were followed up two years later and the researchers found that those who had originally shown a low level of energy use were four times more likely to also show a substantial weight increase (cited in Brownell 1989). These results suggest a relationship between metabolic rate and the tendency for weight gain. If this is the case, then it is possible that some individuals are predisposed to become obese because they require fewer calories to survive than thinner individuals. Therefore, a genetic tendency to be obese may express itself in lowered metabolic rates. However, in apparent contrast to this prediction, there is no evidence to suggest that obese people generally have lower metabolic rates than thin people. To explain these apparently contradictory ﬁndings it has been suggested that obese people may have lower metabolic rates to start with, which results in weight gain and this weight gain itself results in an increase in metabolic rate (Ravussin and Bogardus 1989). Fat cell theory A genetic tendency to be obese may also express itself in terms of the number of fat cells. People of average weight usually have about 25–35 billion fat cells, which are designed for the storage of fat in periods of energy surplus and the mobilization of fat in periods of energy deﬁcit. Mildly obese individuals usually have the same number of fat cells but they are enlarged in size and weight. Severely obese individuals, however, have more fat cells – up to 100–125 billion (Sjostrom 1980). Cell number is mainly determined by genetics; however, when the existing number of cells have been used up, new fat cells are formed from pre-existing preadipocytes. Most of this growth in the number of cells occurs during gestation and early childhood and remains stable once adulthood has been reached. Although the results from studies in this area are unclear, it would seem that if an individual is born with more fat cells then there are more cells immediately available to ﬁll up. In addition, research suggests that once fat cells have been made they can never be lost (Sjostrom 1980). An obese person with a large number of fat cells, may be able to empty these cells but will never be able to get rid of them. Appetite regulation A genetic predisposition may also be related to appetite control. Over recent years researchers have attempted to identify the gene, or collection of genes, responsible for obesity. Although some work using small animals has identiﬁed a single gene that is associated with profound obesity, for humans the work is still unclear. Two children have, however, been identiﬁed with a defect in the ‘ob gene’, which produces leptin which is responsible for telling the brain to stop eating (Montague et al. To support this, researchers have given these two children daily injections of leptin, which has resulted in a decrease in food intake and weight loss at a rate of 1–2 kg per month (Farooqi et al. Despite this, the research exploring the role of genetics on appetite control is still in the very early stages. Behavioural theories Behavioural theories of obesity have examined both physical activity and eating behaviour. Further, at present only 20 per cent of men and 10 per cent of women are employed in active occupations (Allied Dunbar National Fitness Survey 1992) and for many people leisure times are dominated by inactivity (Central Statistical Oﬃce 1994). Although data on changes in activity levels are problematic, there exists a useful database on television viewing which shows that whereas the average viewer in the 1960s watched 13 hours of television per week, in England this has now doubled to 26 hours per week (General Household Survey 1994). This is further exacerbated by the increased use of videos and computer games by both children and adults. In a survey of adolescent boys in Glasgow in 1964 and 1971, whereas daily food diaries indicated a decrease in daily energy intake from 2795 kcals to 2610 kcals, the boys in 1971 showed an increase in body fat from 16. This suggests that decreased physical activity was related to increased body fat (Durnin et al. To examine the role of physical activity in obesity, research has asked ‘Are changes in obesity related to changes in activity?
Sadock and Sadock (2007) suggest that genetic factors also may inﬂuence individual risks for maladaptive response to stress 2.5 mg lozol with amex. Some proponents of psychoana- lytical theory view adjustment disorder as a maladaptive response to stress that is caused by early childhood trau- ma discount 2.5 mg lozol amex, increased dependency, and retarded ego development. Other psychoanalysts put considerable weight on the con- stitutional factor, or birth characteristics that contribute to the manner in which individuals respond to stress. In many instances, adjustment disorder is precipitated by a speciﬁc meaningful stressor having found a point of vulnerability in an individual of otherwise adequate ego strength. Some studies relate a predispo- sition to adjustment disorder to factors such as develop- mental stage, timing of the stressor, and available support systems. When a stressor occurs, and the individual does not have the developmental maturity, available support systems, or adequate coping strategies to adapt, normal functioning is disrupted, resulting in psychological or somatic symptoms. The individual may remain in the denial or anger stage, with inadequate de- fense mechanisms to complete the grieving process. This model considers the type of stressor the individual experiences, the situational con- text in which it occurs, and intrapersonal factors in the predisposition to adjustment disorder. It has been found that continuous stressors (those to which an individual is exposed over an extended period of time) are more com- monly cited than sudden-shock stressors (those that occur without warning) as precipitants to maladaptive function- ing. Intrapersonal factors that have been implicated in the predisposition to adjustment disorder include birth temperament, learned social skills and cop- ing strategies, the presence of psychiatric illness, degree of ﬂexibility, and level of intelligence. Violation of societal norms and rules, such as truancy, van- dalism, reckless driving, ﬁghting 12. Physical complaints, such as headache, backache, other aches and pains, fatigue Common Nursing Diagnoses and Interventions (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Related/Risk Factors (“related to”) [Fixation in earlier level of development] [Negative role modeling] Adjustment Disorder ● 239 [Dysfunctional family system] [Low self-esteem] [Unresolved grief] [Psychic overload] [Extended exposure to stressful situation] [Lack of support systems] [Biological factors, such as organic changes in the brain] Body language (e. Client will verbalize adaptive coping strategies for use when hostile or suicidal feelings occur. Client will demonstrate adaptive coping strategies for use when hostile or suicidal feelings occur. Do this through rou- tine activities and interactions; avoid appearing watchful and suspicious. Close observation is required so that intervention can occur if required to ensure client’s (and others’) safety. Observe for suicidal behaviors: verbal statements, such as “I’m going to kill myself” and “Very soon my mother won’t have to worry herself about me any longer,” and nonverbal behaviors, such as giving away cherished items and mood swings. Clients who are contemplating suicide often give clues regarding their potential behavior. Obtain verbal or written contract from client agreeing not to harm self and to seek out staff in the event that suicidal ideation occurs. Discussion of suicidal feelings with a trusted individual provides some relief to the client. A contract gets the subject out in the open and places some of the responsibil- ity for his or her safety with the client. Help client recognize when anger occurs and to accept those feelings as his or her own. Have client keep an “anger notebook,” in which feelings of anger experienced during a 24-hour period are recorded. Information regarding source of anger, behavioral response, and client’s perception of the situation should also be noted. Discuss entries with client and suggest alternative behavioral responses for those iden- tiﬁed as maladaptive. Act as a role model for appropriate expression of angry feel- ings and give positive reinforcement to client for attempting to conform. It is vital that the client express angry feelings, because suicide and other self-destructive behaviors are often viewed as the result of anger turned inward on the self. Try to redirect violent behavior by means of physical outlets for the client’s anxiety (e. Presence of a trusted individual provides a feeling of security and may help to prevent rapid escalation of anxiety. Have sufﬁcient staff available to indicate a show of strength to client if necessary. This conveys to the client evidence of control over the situation and provides some physical secu- rity for staff. Administer tranquilizing medications as ordered by physi- cian or obtain an order if necessary. Monitor client response for effectiveness of the medication and for adverse side ef- fects. Short-term use of tranquilizing medications such as anxiolytics or antipsychotics can induce a calming effect on the client and may prevent aggressive behaviors. Use of mechanical restraints or isolation room may be re- quired if less restrictive interventions are unsuccessful.
The goal of health Stressors must penetrate the ﬂexible line of defense promotion is included in primary prevention cheap lozol 1.5 mg with visa. Neuman described this line of de- ogy following a reaction to stressors cheap 2.5mg lozol free shipping, appropri- fense as an accordion-like mechanism that acts like ate ranking of intervention priorities, and a protective buffer system to help prevent stressor treatment to reduce their noxious effects. A holistic view of a dynamic open client-client system interacting with environmental stressors, along with client and caregiver collaborative participation in promoting an optimum state of wellness. What are the effects of short- Basic structure term loss of sleep, poor nutrition, or dehydration Basic factors common to all organisms, i. Will these sit- Normal temperature uations increase the possibility for stressor penetra- range tion? The answer is that the possibility for stressor Genetic structure Response pattern penetration may be increased. The actual response Organ strength or depends upon the accordion-like mechanism pre- weakness viously described, along with the other compo- Ego structure Knowns or commonalities nents of the client system. Normal Line of Defense n The normal line of defense represents what the client has become over time, or the usual state of The normal line of defense represents what the client has become over time, or the usual state of wellness. The nurse should determine the client’s usual level of wellness in order to recognize a change in the level of wellness. The normal line of defense is considered dynamic by Neuman, because it can expand or contract over time. Neuman also con- developmental, and spiritual variables occur siders the normal line of defense dynamic because and are considered simultaneously in each client concentric circle. Lines of Resistance Neuman identiﬁed the series of concentric circles that surround the basic structure as lines of resist- defense protects the normal line of defense. When the normal line of defense client has more protection from stressors when the is penetrated by stressors, a degree of reaction, or ﬂexible line expands away from the normal line of signs and/or symptoms, will occur. The opposite is true when the ﬂexible line ance are activated following invasion of the normal moves closer to the normal line of defense. Each fectiveness of the buffer system can be reduced by line of resistance contains known and unknown in- single or multiple stressors. These factors fense can be rapidly altered over a relatively short support the client’s basic structure and the normal time period. States of emergency, or short-term line of defense, resulting in protection of system in- conditions, such as loss of sleep, poor nutrition, or tegrity. Examples of the factors that support the dehydration, are examples of what the client is like basic structure and normal line of defense include in the temporary state that is represented by the the body’s mobilization of white blood cells and ac- ﬂexible line of defense (Neuman, 1995). Accurately as- Maintenance of stability lines are penetrated in both reaction sessing the effects and possible effects and reconstitution phases of environmental stressors (inter-, intra-, Interventions are based on: and extrapersonal factors) and using Degree of reaction Resources appropriate prevention by interventions Goals to assist with client adjustments for an Anticipated outcome optimal level of wellness. The level of wellness affected by a condition and interacts with other may be higher or lower than it was prior to the variables in a positive or negative way. When the lines of resistance example of grief or loss (psychological state), which are ineffective, energy depletion and death occur may inactivate, decrease, initiate, or increase spir- (Neuman, 1995). Neuman believes Basic Structure that spiritual variable considerations are necessary The basic structure at the central core structure for a truly holistic perspective and for a truly caring consists of factors that are common to all organisms. Neuman offered the following examples of basic Fulton (1995) has studied the spiritual variable survival factors: temperature range, genetic struc- in depth. She elaborated on research studies that ture, response pattern, organ strength or weakness, extend our understanding of the following aspects ego structure, and commonalities (Neuman, 1995). She suggested Five Client Variables that spiritual needs include (1) the need for mean- Neuman has identiﬁed ﬁve variables that are con- ing and purpose in life; (2) the need to receive love tained in all client systems: physiological, psycho- and give love; (3) the need for hope and creativity; logical, sociocultural, developmental, and spiritual. The second concept identiﬁed by Neuman is the Psychological refers to mental processes and rela- environment. Developmental refers to life-developmental Neuman has identiﬁed and deﬁned the following processes. Neuman elaborated on the spiritual variable in External environment—inter- and extrapersonal in order to assist readers in understanding that the nature. Examples of trates all other client system variables and supports intrapersonal forces are presented for each variable. The client-client sys- tem can have a complete unawareness of the Physiological variable—degree of mobility, range of spiritual variable’s presence and potential, deny its body function. These factors include the relationships and resources Health is the third concept in Neuman’s model. Extrapersonal fac- Neuman believes that wellness and illness are on tors include education, ﬁnances, employment, and opposite ends of the continuum and that health is other resources (Neuman, 1995). Wellness Neuman (1995) has identiﬁed a third environ- exists when more energy is built and stored than ment as the “created environment.
Families may seek hope where little exists buy lozol 2.5mg lowest price, placing excessive trust/reliance/expectations on individual members of staff; as well as being a symptom of denial generic 1.5 mg lozol fast delivery, this can be particularly stressful for staff. Ventilation Achieving ‘normal’ blood gases with reduced functional alveolar space necessitates forcing larger volumes of gas and/or higher concentrations of oxygen into remaining alveoli. Increased intra-alveolar pressures cause shearing damage (Volotrauma’), while higher concentrations of oxygen may become toxic. Hence, the focus has shifted from normalising blood gases to recruiting alveoli, using smaller tidal volumes and accepting abnormally high arterial carbon dioxide tensions (permissive hypercapnia): Thomsen et al. Permissive hypercapnia should therefore be used cautiously or avoided with: ■ raised intracranial pressure ■ anoxic brain injury (e. Intensive care nursing 270 Pressure limited/controlled ventilation limits peak inflation pressure, and so also limits further volotrauma (Hudson 1995). While preventing or limiting further damage remains the main priority, gas exchange can be optimised by manipulating other aspects of ventilation. Nurses detecting increases in pulmonary pressures (indicative of pulmonary oedema) should alert medical staff. Inverse ratio ventilation increases mean (but not peak) airway pressure (Mulnier & Evans 1995), and prolonged inspiratory phases promote alveolar recruitment, while shorter expiratory phases prevent alveolar collapse. Perfluorocarbon associated gas exchange (liquid ventilation, see Chapter 29) appears to have potential, and is likely to be evaluated rigorously in the near future. However, Lewis and Veldhuizen (1996), while acknowledging that specific dose and intervals remain unknown and the prediction of which patients will benefit remains impossible, argue that exogenous surfactant has proved ineffective because it is given too late. Lung damage occurs in dependent areas, so nursing patients prone for 4 to 8 hours (Brett & Evans 1997) may increase functional residual capacity, improve diaphragmatic motion and help removal of secretions (Mulnier & Evans 1995). Lateral positioning, potentially easier to achieve, also benefits gas exchange (Hinds & Watson 1996). Acute respiratory distress syndrome 271 However, use of the prone position remains controversial (Thomas 1997). Studies consistently show improvements in oxygenation, reduction of shunting, reduced oxygen requirements and reduced mortality (Wong 1998), although available literature may be biased by reluctance to report unsuccessful cases (Ryan & Pelosi 1996). Nursing prone may more usefully prevent potential problems rather than resolve existing ones, and so should be instigated early; too often, like other promising approaches, nursing prone is used once other approaches have failed (Gosheron et al. Recommended duration of prone positioning varies from 30 minutes to 12 hours; Vollman’s (1997) 4–6 hours (drawn from literature review and substantial practice) is recommended until systematic evaluation provides more concrete guidelines. However, a major limitation on prone positioning is staff availability to turn patients. In the absence of suitable equipment (Thomas 1997), some units have experienced significant levels of staff injury from adopting prone positioning. Other nursing complications of prone positioning include access of intravenous lines, positioning of endotracheal and ventilator tubing and aggravation of cardiovascular instability (Thomas 1997). Systemic vasodilation limits intravenous doses, but nebulised prostacyclin has little systemic effect, (half-life being 3–4 minutes (Brett & Evans 1997)). Inhaled nitric oxide appears to have similar benefits (and problems) to nebulised prostacyclin. Steroids inhibit complement-induced leucocyte aggregation and reduce capillary permeability, and so may reduce lung injury (Meduri et al. Increased pulmonary permeability and pulmonary hypertension create excessive interstitial fluid (oedema); plasma albumin displaced into tissues creates an osmotic pull, accentuating tissue oedema and hypovolaemia. Fluid management therefore becomes a delicate balance of providing adequate total body hydration and adequate intravascular volume for perfusion without accentuating problems from oedema. Factors reducing oxygen delivery to tissues (oxygen dissociation curve, see Chapter 18), such as alkalosis, should be avoided. As intravascular volume is the likely main priority, colloids with long half-lives (see Chapter 33) increase colloid osmotic pressure, improving perfusion and potentially reducing oedema. Exogenous albumin has only transient benefits, increased membrane permeability allowing this to leak into tissue. Acute respiratory distress syndrome 273 Albumin levels will reverse as capillary permeability resolves with recovery. Early nutrition provides protein for endogenous albumin production, minimises muscle wasting and promotes immunity. Once commenced, nutrition should be adequate to meet metabolic needs (see Chapter 9). Cardiac management Cardiac management is a careful balance between attempting to meet systemic oxygen demand without causing excessive cardiac workloads. Inotropes may be used to increase cardiac output, with vasodilators to reduce afterload (so increasing perfusion). Some novel medical treatments promise significant benefits, but the mainstay of treatment remains system support. Clinical scenario Ann O’Reilly, a 45-year-old mother of six children who weighs 104 kg, was admitted to hospital for elective ligation of fallopian tubes using keyhole surgery.