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This focus on other care versus only Her findings cheap slimex 10mg with visa weight loss pills 2000, which confirmed many of Luna’s self care was a form of culturally congruent care from 1989 slimex 15mg visa weight loss 757, included the discovery of specific that residents desired in order to maintain healthy generic folk care beliefs on practices that required and beneficial lifeways in an institutional setting. These included pro- staff as these generic care practices were integrated viding for prayer while facing east five times a day; into professional nursing care. Many African American residents desired spiritual or re- gender care findings were similar to those from ligious care and had some diverse aspects of such Luna’s study, revealing a persistence of many re- care rooted in their respective cultures. The find- lated care patterns over time as predicted in the ings of both universality and diversity within the culture care theory. However, the women in pattern of religious or spiritual care supported Wehbeh-Alamah’s study believed the absence of ex- Leininger’s theory, which states that “culture care tended family members in the United States had in- concepts, meanings, expressions, patterns, fluenced male family members’ thinking about the processes, and structural forms of care are different appropriateness of men caring for family members. Anglo American residents received a and participation in direct caregiving by Muslim more formal type of care from their churches, such men (Wehbeh-Alamah, in press). Currently, as a minister coming to the retirement home to Wehbeh-Alamah is conducting an ethnonursing do a worship service or a church choir traveling study of the culture care of Syrian American to the retirement home to entertain the residents. In addi- The nurses at the retirement home practiced tion to discovering the culture care meanings, be- culture care preservation by maintaining the in- liefs, and practices of this group, she will compare volvement of churches in the daily lives of both cul- this study with her previous studies to arrive at uni- tural groups to help residents face living in a versal and diverse care findings among Muslim im- retirement home with increasing disabilities related migrants from diverse cultures living in the United to aging and handicaps, and even dealing with the States. This study revealed their elderly relatives enhanced the health and life- care implications for nurses who practice in retire- ways of both Anglo and African American elders ment homes, nursing homes, apartments for the in the retirement home setting. In contrast with the Anglo In 2000, McFarland & Zehnder (in press) con- American findings, African American spouses, chil- ducted a two-year ethnonursing study of the cul- dren, extended family members, and nonkin who ture care of German American elders living in a were considered family reflected the care pattern of nursing home in a small Midwestern city in the families helping elderly residents. Their findings, which confirmed great grandchildren, nieces, nephews, grandnieces, many of McFarland’s (1997) earlier findings, in- and grandnephews, as well as church members or cluded many care beliefs and practices that required friends who were considered family and were re- culture care preservation. German American elder ferred to as brothers, sisters, or daughters, were in- care practices included caring for fellow residents volved in caring for African American elders. The by assisting confused residents to find their assigned nursing staff recognized the importance of family seat in the dining room or making items for the an- involvement in the care of residents and practiced nual bazaar to raise money to buy flowers for the culture care preservation to maintain culture spe- nursing home courtyard garden, thereby benefit- cific family care practices for residents from each ting all of the residents. Most African American resi- African American elders and was confirmed in this dents had left homes that were in unsafe neighbor- German American study. African American nursing staff recog- from the local German American church and pas- nized the importance of protective care and often tor. The pastor conducted a worship service and a accompanied African American residents when Bible class in German each week. The nursing staff made care, provided by connections with the Lutheran efforts to practice culture care accommodation by Church, was essential to German American elders negotiating to take the residents outside to sit on in maintaining their traditional lifeways and health the small grass strip around the perimeter of the in the nursing home setting. Professional nurses need to be more ac- ethnonursing studies of elder care conducted by tively involved in culture care repatterning as co- transcultural nurses with diverse cultures world- participants with elders to restructure lifeway wide. This will hopefully lead to the discovery of practices, care routines, and the environmental universal and diverse care meanings, beliefs, and context of nursing homes (including room designs practices to meet the needs of the increasing num- and privacy considerations). Culture care restruc- bers of elders worldwide who value generic culture- turing of these care-related concerns can only be specific care to reaffirm their cultural identities in accomplished when nurses assume an advocacy the latter phase of their lives. The culture care theory, with the ethnonursing method, assisted the researcher in The purpose of the culture care theory (along this study in the discovery of action and decision with the ethnonursing method) has been to modes that were culturally specific for Anglo and discover culture care with the goal of using African American elders residing in a long-term the knowledge to combine generic and care institution. The theory fo- culturally congruent nursing care using the cuses on a long-neglected area in nursing three modes of nursing actions and decisions practice—culture care—that is most relevant that is meaningful, safe, and beneficial to to our multicultural world. The clinical Universality is depicted in the sunrise enabler use of the three major care modes (culture as a rising sun. This visual metaphor is par- care preservation or maintenance; culture ticularly apt as the future of the culture care care accommodation or negotiation; and cul- theory shines brightly indeed, because it is ture care repatterning or restructuring) by holistic, comprehensive, and fits discovering nurses to guide nursing judgments, decisions, care related to diverse and similar cultures, and actions is essential in order to provide contexts, and ages of people in familiar and culturally congruent care that is beneficial, naturalistic ways. The theory is useful to satisfying, and meaningful to the people nurses and to nursing and to professionals in nurses serve. The studies of the four cultures other disciplines such as physical, occupa- just reviewed (Lebanese Muslim, Anglo tional, and speech therapy, medicine, social American, African American, and German work, and pharmacy. Health-care practition- Americans) substantiate that the three modes ers in other disciplines are beginning to use are care centered and are based on the use of this theory because they also need to become generic care (emic) knowledge along with knowledgeable about and sensitive and re- professional care (etic) knowledge obtained sponsible to people of diverse cultures who from research using the culture care theory need care (Leininger, 2002). This chapter has reviewed only a small selection of the culture care findings from ethnonursing research studies conducted over the past four References decades. Culture care expression, meanings, and experi- ings of interest to practicing nurses who care ences of pregnant Mexican American women within Leininger’s for clients of all ages from diverse and similar culture care theory. Mexican American women’s expressions of the tional and community contexts around the meaning of culturally congruent prenatal care. Nursing and anthropology: Two worlds to found in the Journal of Transcultural Nursing blend. Transcultural nursing presents an exciting (1989 to 2004) and in the numerous books challenge. Caring: The essence and central focus Nurses in clinical practice are advised to con- of nursing. Nursing Research Foundation Report, 12(1), sult a list of research studies and doctoral dis- 2–14.

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The second-generation group of antihistamines is less lipophilic than the pre- vious generation and thus cross the blood–brain barrier less readily effective slimex 15mg weight loss pills not approved by fda, which accounts for the lower levels of sedation observed with the newer drugs order slimex 10 mg free shipping weight loss 80 20 rule. Thus, although the second-generation antihistamines generally produce less seda- tion than first-generation compounds, if therapeutic doses are exceeded, the so-called nonsedating antihistamines become sedating and can impair driving. Assessment in the Field by Police In the United Kingdom, if a police officer stops a driver, for whatever reason, and believes the driver is unfit to drive, it is highly likely that a road- side breath test will be conducted. That is not the case in the United States, where field breath testing is only permitted in some states, and then only for drivers under the age of 21 years (22). Stopping a vehicle is a seizure, but it may be reasonable if the police officer has a justifiable suspicion that an offense is being committed. This then gives them the probable cause to carry out subsequent tests similar to the Sec- tion 4 procedure to prove impairment. Until recently in the United Kingdom, police traf- fic officers received little or no training in the recognition of signs and symp- toms of drug effects. Police officers were trained to observe and document known indicators of drug use and impairment. Instead of breath testing, a series of standardized field sobriety tests, which include psychomotor and divided attention tests, is conducted. If alco- hol is suspected, the following tests are carried out: walk and turn test, one-leg stand, and the horizontal gaze nystagmus test. In addition, if drugs are sus- pected, a Romberg balance test is also carried out. Unlike chemical tests (with refusal to submit possibly resulting in immediate license suspension), drivers in the United States are not legally required to take any field sobriety tests; however, if the driver submits, the results can be introduced as additional evi- dence of impairment. These tests are all divided attention tests, which assess the individual’s balance and coordination, as well as the ability to follow simple instructions (i. They are as follows: • Horizontal gaze nystagmus: nystagmus may be caused by any number of condi- tions, but its presence could indicate drugs or alcohol. Eight impairment indicators are measured; if two of the eight are present, impairment would be indicated. Some drugs alter the body’s inter- nal clock and make the person act faster or slower than normal. Interview with the arresting officer: the purpose is to ascertain baseline informa- tion, including the circumstances of the arrest, whether an accident occurred, whether drugs were found, and if so, what they looked like. Preliminary examination: the purpose of the preliminary examination is to deter- mine whether if there is sufficient reason to suspect a drug offense and to try to exclude any underlying medical problems. General observations and details of any current medical problems are ascertained, and the first measurement of the pulse is taken. If no signs of drug influence are found, the procedure is termi- nated; if any medical problems are found, a medical assessment is obtained, and if drugs are still suspected, a full assessment is carried out. If at any time during the assessment a serious medical condition is suspected, a medical opinion will be obtained. Eye examination: the driver is assessed for horizontal gaze nystagmus, vertical gaze nystagmus, and convergence. Divided attention tests: once at a police station, the Romberg balance test, walk and turn test, one-leg stand test, and the finger-to-nose test are carried out. These are all examples of divided attention tests whereby balance and movement tests are performed in addition to remembering instructions. Vital signs examination: blood pressure, temperature, and a second recording of the pulse are carried out. Darkroom examination: pupil size is measured in room light and then in near total darkness, using both indirect artificial light and direct light. Muscle tone: limb tone is assessed as some drugs cause rigidity, whereas others, for example, alcohol, cause flaccidity. Injection sites examination: the purpose is to seek evidence of intravenous or injection drug abuse. Toxicology testing: at the same time, samples are obtained for toxicological examination, either a blood or urine sample being taken for analysis of common drugs. The mere detection of a drug does not prove impairment unless, of course, the jurisdiction has per se laws whereby the detection of drugs at some predeter- mined level is ruled, by law, to be proof of impairment. Whether the examination is carried out by a forensic physician in London or an emergency room physician in San Francisco, the aim of the examination is to exclude any medical condition other than alcohol or drugs as the cause of the driver’s behavior. The differential diagnosis is wide and includes head injury, neurological problems (e. The procedure should include introductory details, full medical history, and clinical examination. Similar forms are not available in the United States, but there is nothing to prevent any emergency department in the United States from drafting and providing a similar document. Even if no special form is provided, most of the relevant material will have been (or at least should be) recorded in the emergency department record.

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Check that any supplies shipped to the site since the last visit were received in good condition and are properly stored generic 15mg slimex with amex weight loss pills to lose 5 pounds. If applicable cheap 15 mg slimex fast delivery weight loss 58, ensure that randomization procedures are being followed, blind is being maintained, randomization codebreak envelopes are intact (sealed and stored properly) and a chronological sequence of allocation to treatment is being followed Verify correct biological sample collection (especially number, type, and timing), correct procedures for assays (if applicable), and labeling, storage and transportation of specimens or samples. The dates of sample collection, receipt, analysis and reporting should be checked to ensure that samples are analyzed promptly, and that investigators are informed of results and review them promptly Ensure continued acceptability of facilities, staff and equipment. Ensure that the reference range, documentation of certification and proficiency testing, licensing, and accreditation, for the clinical laboratory are still current. Document any changes in clinical site personnel and, if changes have occurred, collect evidence of suitability of new personnel. Ensure that new staff are fully briefed on the requirements of the protocol and study procedures and arrange any training of new personnel, if necessary. This may be acceptable, if these data would not normally be entered in medical records, and if knowledge of such data is not required by the 12. Other restricted methods Source data verification is the process of verifying of access to source documents (e. Thereafter, review by the data management onto computers or direct entry of patient informa- department is another extremely important means tion onto computers by physicians). It is a lengthy and complex The primary purpose of source documents is process and there are few guidelines and regula- for the care of the study subject from a clinical tions for reference. As time goes lection forms) generally cannot substitute as by, it becomes more and more difficult to correct source documents. Slow processing usually means that data lose generally be supported by source data in source credibility. The medical file should clearly indicate the full name, birth date, and hospital/clinic/health service number of the study subject Eligibility of study subjects. At a minimum, demographic characteristics, for example sex, weight and height, diagnoses, for example major condition for which subject was being treated, and other ‘hard’ data, for example laboratory results within a specified range or normal chest X-ray, should be clearly indicated. If the medical file has little or no information concerning medical history, it would not support selection of the subject Indication of participation in the study. The medical file should clearly show that the subject was in a clinical study in case the information is necessary for future clinical care Consent procedures. The original signed consent form should be maintained with the subject’s medical files or in the investigator files and an indication that consent was obtained (with the date specified) should be noted in the medical files. Signatures and dates must be checked carefully to ensure that the correct individuals were involved in the consent procedure and that consent was obtained prior to any study intervention Record of exposure to study medication/device. The medical file should clearly indicate when treatment began, when treatment finished, and all intervening treatment dates Record of concomitant medications/devices. Concomitant medication/device use must be explicable by an appropriate indication and must be consistent from visit to visit. The medical history should be reviewed to determine whether medical conditions arising during the study already existed at baseline. The dispensing records, which are normally separate from the medical file, must also be examined to determine consistency Visit dates. Present and future clinical care of the study subject is the most important factor in determining whether or not measured variables should be recorded in the medical file. The investigator should record what he/she would normally record to care for the study subject, but also take into account any recording needed because of the special circumstances of a clinical study. Thus, requests for entered in the computer, the data recorded in data data clarification and all resolution of queries must listings and cross-tabulations, the data entered into be documented. All data changes must be author- statistical and clinical study reports and finally the ized by the investigator ultimately. Archiving Requisition of study medication/device (includ- ing placebo and comparator products, if relevant) Systems must be in place to ensure that documents must be initiated at an early stage to allow sufficient will be securely retained for a long period of time to procure the study medications/devices time. The purpose of archiving is to safeguard all and to prepare the final labeling and packaging, documentation that provides evidence that a clinical taking into account any special circumstances for study has been conducted in accordance with the blind studies and for import requirements. Further, the investigator must archive all necessary documents for a minimum of 15 years – the usual industry standard. The recipient must be in the manufacturing facility usually report that particularly instructed to record the exact date of they assume no further responsibility once the receipt of the clinical supplies at the study site. Control of study medications/devices at study sites Overall accountability of study medications/devices Evidence of careful control at the study site is im- perative, and naturally it is difficult to standardize Overall accountability must documented and the situation across many study sites and many reviewed. Security, correct storage and accurate and the final returns must be undertaken and all documentation of dispensing and inventory are discrepancies must be explained. Systems to ensure and assess compli- and destruction must be carefully documented ance with the required use of the product being to also allow assessment of possible detrimental studied must be established. All unused and returned trained to check on these features and ensure that medications/devices, empty containers, devices, all site personnel are fully briefed. All discrepancies and the reasons for any non- site must specify that supplies are only for clinical returns must be documented and explained.

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