However cheap 0.25 mg digoxin visa 5 htp and hypertension, Sklar and Anisman (1981) argued that an increase in stress increased the promotion of cancer not its initiation (see Chapter 11 for a discussion of the relationship between stress and illness) buy digoxin 0.25mg with visa hypertension pathophysiology. It has also been suggested that life events play a role in cancer (see Chapter 10 for a discussion of life events). A study by Jacobs and Charles (1980) examined the differences in life events between families who had a cancer victim and families who did not. They reported that in families who had a cancer victim there were higher numbers who had moved house, higher numbers who had changed some form of their behaviour, higher numbers who had had a change in health status other than the cancer person, and higher numbers of divorces indicating that life events may well be a factor contributing to the onset of cancer. They identified 29 studies, from 1966 to 1997, which met their inclusion criteria (adult women with breast cancer, group of cancer-free controls, measure of stressful life events) and concluded that although several individual studies report a relationship between life events and breast cancer, when methodological problems are taken into account and when the data across the different studies is merged ‘the research shows no good evidence of a relationship between stressful life events and breast cancer’. Control also seems to play a role in the initiation and promotion of cancer and it has been argued that control over stressors and control over environmental factors may be related to an increase in the onset of cancer (see Chapter 11 for a discussion of control and the stress–illness link). If an individual is subjected to stress, then the methods they use to cope with this stress may well be related to the onset of cancer. For example, maladaptive, disengagement coping strategies, such as smoking and alcohol, may have a relationship with an increase in cancer (see Chapters 3 and 11 for a discussion of coping). Bieliauskas (1980) highlighted a relationship between depression and cancer and suggests that chronic mild depression, but not clinical depression may be related to cancer. Over the past few years there has been some interest in the relationship between personality and cancer. Temoshok and Fox (1984) argued that individuals who develop cancer have a ‘type C personality’. A type C personality is described as passive, appeasing, helpless, other focused and unexpressive of emotion. Eysenck (1990) described ‘a cancer-prone personality’, and suggests that this is characteristic of individuals who react to stress with helplessness and hopelessness, and individuals who repress emotional reactions to life events. An early study by Kissen (1966) sup- ported this relationship between personality and cancer and reported that heavy smokers who develop lung cancer have a poorly developed outlet for their emotions, perhaps suggesting type C personality. At follow-up they described the type of individual who was more likely to develop cancer as having impaired self-awareness, being self-sacrificing, self-blaming and not being emotionally expressive. The results from this study suggest that those individuals who had this type of personality were 16 times more likely to develop cancer than those individuals who did not. However, the relationship between cancer and personality is not a straightforward one. It has been argued that the different personality types predicted to relate to illness are not distinct from each other and also that people with cancer do not consistently differ from either healthy people or people with heart disease in the predicted direction (Amelang and Schmidt-Rathjens 1996). Low control suggests a tendency to show feelings of helplessness in the face of stress. Commitment is defined as the opposite of alienation: individuals high in commitment find meaning in their work, values and personal relationships. Individuals high in challenge regard potentially stressful events as a challenge to be met with expected success. The emotional state of breast cancer sufferers appears to be unrelated to the type of surgery they have (Kiebert et al. However, persistent deterioration in mood does seem to be related to previous psychiatric history (Dean 1987), lack of social support (Bloom 1983), age, and lack of an intimate relationship (Pinder et al. Women with breast cancer often report changes in their sense of femininity, attractiveness and body image. This has been shown to be greater in women who have radical mastectomies rather than lumpectomies (e. Cognitive responses Research has also examined cognitive responses to cancer and suggests that a ‘fighting spirit’ is negatively correlated with anxiety and depression whilst ‘fatalism’, ‘helplessness’ and ‘anxious preoccupation’ is related to lowered mood (Watson et al. First, they made a search for meaning, whereby the cancer patients attempted to understand why they had developed cancer. Meanings that were reported included stress, hereditary factors, ingested carcinogens such as birth control pills, environmental carcinogens such as chemical waste, diet, and a blow to the breast. Second, they also attempted to gain a sense of mastery by believing that they could control their cancer and any relapses. Such attempts at control included meditation, positive thinking, and a belief that the original cause is no longer in effect. This involved social comparison, whereby the women tended to analyse their condition in terms of others they knew. Taylor argued that they showed ‘downward comparison’, which involved comparing themselves to others worse off, thus improving their beliefs about their own situation. According to Taylor’s theory of cognitive adaptation, the combination of meaning, mastery and self-enhancement creates illusions which are a central component of attempts to cope. Psychosocial interventions have therefore been used to attempt to alleviate some of the symptoms of the cancer sufferer and to improve their quality of life.

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After the infants habituated to this display cheap digoxin 0.25 mg without a prescription blood pressure regulation, the presentation was changed such that the puppet jumped a different number of times purchase digoxin 0.25mg otc blood pressure low heart rate high. Karen Wynn found that babies that had habituated to a puppet jumping either two or three times significantly increased their gaze when the puppet began to jump a different number of times. Cognitive Development During Childhood Childhood is a time in which changes occur quickly. During this time the child learns to actively manipulate and control the environment, and is first exposed to the requirements of society, particularly the need to control the bladder and bowels. According to Erik Erikson, the challenges that the child must attain in childhood relate to the development of initiative, competence, and independence. Children need to learn to explore the world, to become self-reliant, and to make their own way in the environment. Neurological changes during childhood provide children the ability to do some things at certain ages, and yet make it impossible for them to do other things. This fact was made apparent through the groundbreaking work of the Swiss psychologist Jean Piaget. During the 1920s, Piaget was administering intelligence tests to children in an attempt to determine the kinds of logical thinking that children were capable of. In the process of testing the children, Piaget became intrigued, not so much by the answers that the children got right, but more by the answers they got wrong. Piaget believed that the incorrect answers that the children gave were not mere shots in the dark but rather represented specific ways of thinking unique to the children‘s developmental stage. Just as almost all babies learn to roll over before they learn to sit up by themselves, and learn to crawl before they learn to walk, Piaget believed that children gain their cognitive ability in a developmental order. These insights—that children at different ages think in fundamentally different ways—led to Piaget‘s stage model of cognitive development. Piaget argued that children do not just passively learn but also actively try to make sense of their worlds. He argued that, as they learn and mature, children develop schemas—patterns of knowledge in long-term memory—that help them remember, organize, and respond to information. Furthermore, Piaget thought that when children experience new things, they attempt Attributed to Charles Stangor Saylor. Piaget believed that the children use two distinct methods in doing so, methods that he called assimilation andaccommodation (see Figure 6. If children have learned a schema for horses, then they may call the striped animal they see at the zoo a horse rather than a zebra. In this case, children fit the existing schema to the new information and label the new information with the existing knowledge. When a mother says, ― “No, honey, that‘s a zebra, not a horse,‖ the child may adapt the schema to fit the new stimulus, learning that there are different types of four-legged animals, only one of which is a horse. Piaget‘s most important contribution to understanding cognitive development, and the fundamental aspect of his theory, was the idea that development occurs in unique and distinct stages, with each stage occurring at a specific time, in a sequential manner, and in a way that allows the child to think about the world using new capacities. Object permanence Children acquire the ability to internally represent the Theory of mind; rapid world through language and mental imagery. They also increase in language Preoperational 2 to 7 years start to see the world from other people‘s perspectives. They can Concrete increasingly perform operations on objects that are only operational 7 to 11 years imagined. Conservation Adolescents can think systematically, can reason about Formal 11 years to abstract concepts, and can understand ethics and scientific operational adulthood reasoning. Abstract logic The first developmental stage for Piaget was the sensorimotor stage, the cognitive stage that begins at birth and lasts until around the age of 2. It is defined by the direct physical interactions that babies have with the objects around them. During this stage, babies form their first schemas by using their primary senses—they stare at, listen to, reach for, hold, shake, and taste the things in their environments. Piaget found, for instance, that if he first interested babies in a toy and then covered the toy with a blanket, children who were younger than 6 months of age would act as if the toy had disappeared completely—they never tried to find it under the blanket but would nevertheless smile and reach for it when the blanket was removed. Piaget found that it was not until about 8 months that the children realized that the object was merely covered and not gone. Piaget used the term object permanence to refer to the child’s ability to know that an object exists even when the object cannot be perceived. Video Clip: Object Permanence Children younger than about 8 months of age do not understand object permanence. At about 2 years of age, and until about 7 years of age, children move into thepreoperational stage. During this stage, children begin to use language and to think more abstractly about objects, but their understanding is more intuitive and without much ability to deduce or reason. The thinking is preoperational, meaning that the child lacks the ability to operate on or transform objects mentally. In one study that showed the extent of this inability, [10] Judy DeLoache (1987) showed children a room within a small dollhouse. The researchers took the children to another lab room, which was an exact replica of the dollhouse room, but full-sized.

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A decrease in self-esteem quality 0.25mg digoxin blood pressure 3020, if one is unable to meet self-expectations or the expectations of others (even if these expectations are only perceived by the individual as unfulfilled) digoxin 0.25mg blood pressure kits at walgreens. Separation from these familiar and per- sonally valued external objects represents a loss of material extensions of the self. Some texts differentiate the terms mourning and grief by describing mourning as the psychological process (or stages) through which the individual passes on the way to successful adaptation to the loss of a valued object. Grief may be viewed 390 Loss and Bereavement ● 391 as the subjective states that accompany mourning, or the emo- tional work involved in the mourning process. For purposes of this text, grief work and the process of mourning are collectively referred to as the grief response. Theoretical Perspectives on Loss and Bereavement (Symptomatology) Stages of Grief Behavior patterns associated with the grief response include many individual variations. However, sufficient similarities have been observed to warrant characterization of grief as a syndrome that has a predictable course with an expected resolution. Early theorists, including Kübler-Ross (1969), Bowlby (1961), and Engel (1964), described behavioral stages through which indi- viduals advance in their progression toward resolution. Some individuals may reach acceptance, only to revert to an earlier stage; some may never complete the sequence; and some may never progress beyond the initial stage. William Worden (2009), offers a set of tasks that must be processed to complete the grief response. He suggests that it is possible for a person to accomplish some of these tasks and not others, resulting in an incomplete bereavement and thus impairing further growth and development. Behaviors associated with each of these stages can be observed in individuals experiencing the loss of any concept of personal value. Feelings associated with this stage include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blam- ing of others may lead to feelings of anger toward the self and others. The anxiety level may be elevated, and the in- dividual may experience confusion and a decreased ability to function independently. The individual attempts to strike a bargain with God for a second chance or for more time. This is a very painful stage, dur- ing which the individual must confront feelings associated with having lost someone or something of value (called reactive depression). Feelings associ- ated with an impending loss (called preparatory depression) are also confronted. Examples include permanent life- style changes related to the altered body image or even an impending loss of life itself. Regression, withdrawal, and social isolation may be observed behaviors with this stage. Therapeutic intervention should be available, but not imposed, and with guidelines for implementation based on client readiness. The individual has worked through the behaviors associated with the other stages and either accepts or is resigned to the loss. The client is less preoccupied with what has been lost and increasingly interested in other aspects of the environ- ment. These behaviors are an attempt to facilitate the passage by slowly disengaging from the environment. He implied that these behaviors can be observed in all individu- als who have experienced the loss of something or someone of value, even in infants as young as 6 months. This stage is characterized by a feeling of shock and disbelief that the loss has occurred. During this stage, the individual has a profound urge to recover what has been lost. Behaviors associated with this stage include a preoccupation with the loss, intense weeping and expressions of anger toward the self and others, and feelings of ambivalence and guilt associ- ated with the loss. Feelings of despair occur in response to the realization that the loss has occurred. Activities of daily living become increasingly disorganized, and behavior is characterized by restlessness Loss and Bereavement ● 393 and aimlessness. Efforts to regain productive patterns of behavior are ineffective and the individual experiences fear, helplessness, and hopelessness. Perceptions of visualizing or being in the presence of that which has been lost may occur. Social isolation is com- mon, and the individual may feel a great deal of loneliness. The individual begins a reinvestment in new relationships and indicates a readiness to move forward with- in the environment. The initial reaction to a loss is a stunned, numb feeling and refusal by the individual to acknowledge the reality of the loss.

Therapy should continue through the winter season before being tapered to 150 mg/day for 2 weeks prior to discontinuation in early spring generic 0.25 mg digoxin with amex blood pressure goes up and down. Pain related to side effect of abdominal pain (atomoxetine buy discount digoxin 0.25mg on line blood pressure 80 over 40, bupropion) or headache (all agents). Nursing implications related to each side effect are designated by an asterisk (*). A careful personal and fam- ily history of heart disease, heart defects, or hypertension should be obtained before these medications are prescribed. Careful monitoring of cardiovascular function during administration must be ongoing. To do so could initiate the following syndrome of symptoms: nau- sea, vomiting, abdominal cramping, headache, fatigue, weakness, mental depression, suicidal ideation, increased dreaming, and psychotic behavior. Constipation (atomoxetine, bupropion, clonidine, guanfacine) * Increase fiber and fluid in diet, if not contraindicated. Dry mouth (clonidine and guanfacine) * Offer the client sugarless candy, ice, frequent sips of water * Strict oral hygiene is very important. Potential for seizures (bupropion) * Protect client from injury if seizure should occur. Instruct family and significant others of clients on bupropion ther- apy how to protect client during a seizure if one should occur. Ensure that doses of the immediate release medica- tion are administered 4 to 6 hours apart, and doses of the sustained release medication at least 8 hours apart. Severe liver damage (with atomoxetine) * Monitor for the following side effects and report to physi- cian immediately: itching, dark urine, right upper quad- rant pain, yellow skin or eyes, sore throat, fever, malaise. Rebound syndrome (with clonidine and guanfacine) * Client should be instructed not to discontinue therapy abruptly. To do so may result in symptoms of nervous- ness, agitation, headache, and tremor, and a rapid rise in blood pressure. Be aware of the need for possible alteration in insulin requirements because of changes in food intake, weight, and activity. Report any of the following side effects to the physician immediately: shortness of breath, chest pain, jaw/left arm pain, fainting, seizures, sudden vision changes, weakness on one side of the body, slurred speech, confusion, itching, dark urine, right upper quadrant pain, yellow skin or eyes, sore throat, fever, malaise, increased hyperactivity, believing things that are not true, or hearing voices. Refer to written materials furnished by health-care providers for safe self-administration. To develop a basic trust in (Birth–18 mistrust the mothering figure and months) be able to generalize it to others Early Autonomy vs. To gain some self-control childhood shame and and independence within (18 months– doubt the environment 3 years) Late Initiative vs. To achieve a sense of self- (6–12 years) inferiority confidence by learning, competing, performing successfully, and receiv- ing recognition from significant others, peers, and acquaintances Adolescence Identity vs. To integrate the tasks (12–20 years) role mastered in the previous confusion stages into a secure sense of self Young adult- Intimacy vs. To form an intense, lasting hood isolation relationship or a commit- (20–30 years) ment to another person, a cause, an institution, or a creative effort Adulthood Generativity To achieve the life goals while vs. Differentiation Commencement of a primary recogni- tion of separateness from the mothering figure 10–16 b. Practicing Increased independ- months ence through loco- motor functioning; increased sense of separateness of self 16–24 c. Rapprochement Acute awareness of months separateness of self; learning to seek “emotional refueling” from mothering figure to maintain feeling of security 24–36 months d. Consolidation Sense of separate- ness established; on the way to object constancy (i. Punishment and Behavior is moti- (common from obedience vated by fear of ages 4 to orientation punishment 10 years) 2. Interpersonal Behavior is (common from concordance motivated by ages 10 to 13 orientation the expecta- years and into tions of others; adulthood) strong desire for approval and acceptance 4. Social contract Behavior is moti- tional (can legalistic vated by respect occur from orientation for universal adolescence on) laws and moral principles and guided by an internal set of values 6. Psychiatric/mental health nursing: Concepts of care in evidence-based practice (6th ed. She acknowl- alcohol Preventing attended edge the every day unaccept- nursing existence and cannot able or school to of a real stop fails to undesirable please her situation or acknowl- thoughts or parents. Identifica- A teen- Repression: An accident tion: ager who Involuntar- victim can An attempt required ily blocking remember to increase lengthy unpleasant nothing self-worth rehabilita- feelings and about his by acquir- tion after experiences accident. Intellectuali- S’s husband Sublimation: A mother zation: is being Rechan- whose son An attempt transferred neling of was killed to avoid with his job drives or by a drunk expressing to a city far impulses driver actual emo- away from that are chan- tions asso- her parents. Introjection: Children Suppression: Scarlett Integrating integrate The O’Hara the beliefs their par- voluntary says, “I and values ents’ value blocking of don’t want of another system unpleasant to think individual into the feelings and about that into one’s process of experiences now.

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