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Even when the patient is unrespon- or with cooling techniques such as bathing with cool sive buy kamagra gold 100 mg on-line experimental erectile dysfunction treatment, the mouth should be cleaned and moistened at water kamagra gold 100mg otc erectile dysfunction gnc. When a decision is made to give antibiotics, a broad-spectrum oral antibiotic or once-daily injection regular intervals for patient comfort and to lessen family distress. Other symptoms such as dyspnea associated with pneumonia, or dysuria and urinary frequency associated with urinary tract infection, Urinary Symptoms should be addressed to relieve physical distress. Urinary incontinence, dysuria, and frequency can be par- ticularly disturbing symptoms for patients, especially if Bereavement mobility is impaired. For symptoms Anticipatory grieving, or sadness about the expected of incontinence and frequency, a postvoid residual (PVR) death, should be acknowledged and support offered to volume should be documented. Communication before than 150 mL, an indwelling catheter should be left in death between the patient and friends and family is place or intermittent catheterization performed regu- important when possible. Indwelling catheters may be used for easing care- family members need to understand that death is likely, giver burden or avoiding moving patients with severe have adequate time to process that information, and pain; however, they are associated with urinary tract spend time with each other. Information about what to infections in all patients in whom they are in place for expect as disease progresses and death approaches may more than about 1 week. When retention may respond to bethanechol (Urecholine) 5 to death seems imminent, the patient and family should be 10 mg bid to tid. In the absence of elevated PVR, toltero- advised and given the opportunity to "say good-bye. Dysuria can sometimes be reduced with a caregiver team should participate in bereavement ac- bladder anesthetic, such as pyridium 100 to 200 mg p. Women with atrophic changes of the urethral meatus adequate for the family to know that the physician and external genitalia may have improved bladder func- recognizes their sense of loss. Some physicians maintain tion and reduction in irritative symptoms with small tickler files to call or to send a note to the patient’s family amounts of topical estrogen cream applied to the urethral on the anniversary of the patient’s death. Skin Care Skin should be kept clean and dry and decubitus ulcers prevented, particularly in cachectic or malnourished Conclusion patients. Prophylaxis includes avoiding friction, reducing prolonged pressure by turning every 2 h, or using an air Care near the end of life focuses on optimizing quality or water mattress when patients become bedbound; of life for the patient and their family and minimizing however, in some situations, these interventions need to symptoms. Death Foretold: Prophecy and Prognosis The process of caring for patients near the end of life in Medical Care. Chicago: University of Chicago Press; should be learned by all health providers and improved 1999. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: A Report by the Hastings Center. Center for Disease Control and Prevention, Bloomington: Indiana University Press; 1987. Chicago: of Alzheimer’s disease in a community population of older American Medical Association; 1986. Changes proxy counseling program for patients with Alzheimer’s in the location of death after passage of Medicare’s disease. Advance directives for seriously ill hospitalized Evaluative Sciences, Dartmouth Medical School Hanover patients: effectiveness with the patient self-determination NH; 1998. A program of hospice and use of cardiopulmonary resuscitation in seriously ill hospi- palliative care in a private, nonprofit US teaching hospital. A national survey ogy of do-not-resuscitate orders: disparity by age, diagnosis, of end-of-life care for critically ill patients. Changes in orders limiting ysis and withdrawal of mechanical ventilation at the end of care and the use of less aggressive care in a nursing home life. Medical decision-making in the last Costs and Use of Care in the Last Year of Life. Longevity and Medicare active euthanasia and assisted suicide in Dutch nursing expenditures. The President’s Commission for the Study of Ethical oxygen on dyspnea in hypoxemic terminal-cancer patients. Strength For Caring (888) ICARE80 Hotline, associated with Alzheimer disease: variation by level of www. Patterns of pre-death service use by nal illness in the advanced cancer patient: Pain and other dementia patients with a family caregiver. Management of symptoms in dying patients and their families in hospital pain in elderly patients with cancer. This page intentionally left blank 27 Sources of Suffering in the Elderly Maria Torroella Carney and Diane E. Meier The relief of suffering is one of the primary aims of med- chapter attempts to address both physical and psycho- icine.

Unfortunately generic kamagra gold 100mg fast delivery erectile dysfunction pills from canada, this collaborative approach buy 100 mg kamagra gold fast delivery how does the erectile dysfunction pump work, which in- cluded each member of the family regardless of age, is frequently over- looked in favor of traditional verbal family therapy. By way of example, Kor- ner and Brown’s study (cited in Lund, Zimmerman, & Haddock, 2002) surveyed 173 therapists and found that 40% never included children in family therapy sessions, while 31% invited children yet did not include them as participants. Because of this diversity, the incorporation of the entire family unit produces, out of necessity, interventions that require both cognitive and emotional considerations. With these considerations in mind, the interactive experience of art therapy and its inherent emo- tional expression allow symbolic communication between parents and children regardless of age or ability. Consequently, "when the two disci- plines, family therapy and art therapy, are integrated into family art ther- apy, they do so sharing theoretical frameworks of personality development, family systems, and the art therapy process" (Arrington, 2001, p. As with group therapy, the use of art media provides an opportunity for the clinician to watch as the familial dynamics unfold not merely on a ver- bal level but in a way that reveals the unconscious motivations, behaviors, and feelings that make up the family interactional patterns. And this sym- bolic communication, from a psychodynamic framework, is the focus of this chapter. Derivatives of the psychoanalytic school, dynamically ori- ented family art therapists are interested in both internal processes and in- 275 The Practice of Art Therapy teractional ones and place an emphasis on understanding and working with the unconscious mind. However, no discussion of psychodynamic family therapy is complete without a dialogue focused on transference reactions as agents of under- standing and change. In my practice I use an analysis of the transference from a here-and-now perspective. In this way, the patient-therapist rela- tionship becomes an integral aspect of therapy, not through scrutiny only of infantile conflict but through clients’ pervasive maladaptive relational patterns (Bauer, 1993). This rendering is an adap- tation of the Non-Verbal Family Art Task (Landgarten, 1987), in which the entire family draws on a single sheet of paper at predetermined times. The daughter, whom I will call Frances, had been referred to out-of- home placement due to increasingly aggressive, intrusive, and impulsive behaviors. My first individual meetings with Frances were met with loud resistance quickly followed by temper tantrums. I knew that she had been involved in therapy for many years and often utilized coping strategies of aggressive iso- lation when she felt she was under scrutiny. Family Therapy Directives validate the anxiety by commenting aloud on our relationship, effectively bringing the acting-out behavior into a conscious realm where we could explore it. Roughly 1 month after beginning individual therapy, Frances was able to attend to the sessions without regression. However, I did not begin fam- ily art therapy sessions until 3 months later because it was important to build a strong therapeutic alliance based upon process illumination, con- tainment, and ego-enhancing directives to develop awareness. Throughout the task, Frances frequently made comments like "Don’t look" or "Don’t watch me. Frances’s form items are gath- ered into the center of the mural, while her mother’s drawings surround them in a metaphor of protection and enmeshment. As with other art therapy techniques, a family mural drawing allows the participants to be both contributor and observer. This provides the thera- peutic hour with rich clinical material that in many ways is incontrovert- ible. This symbolic communication metaphorically parallels the interac- tional patterns of the entire family. Moreover, the artwork’s permanency lends itself particularly well to interpreting transference reactions, as the artwork provides a tangible object that gives meaning to the experience as well as the interpretation. In these ways, the family art mural provides the mental health clinician with both interrelational examples and intra- psychic concerns that are often disguised in purely verbal communication. However, pay particular attention to the figures on the left side (drawn by the mother to represent the mother-daughter dyad). Frances’s facial characteristics appear blithely secure, while the mother, clutching her daughter’s hand, looks on with an expression of reflexive hostility and disapproval. Although this representation of the therapist could easily be a realistic perception based upon numerous other therapists, helping professionals, and counselors in this young child’s life, it is the "Do Not En- ter" sign that conveys the conflict-laden anxiety as it moves from the fa- milial home to the therapist. With her temper tantrums, her exclamations of "Don’t look at me," and her outright pictorial statements of "Do not en- ter," Frances figuratively communicated the criticism that she both ex- pected and feared. As Butler and Strupp (1993) have noted, "the interper- sonal problems that emerge with the therapist are assumed to be similar in 277 The Practice of Art Therapy form to the chronic, maladaptive interpersonal patterns that underlie the patient’s difficulties in living, expressed as symptoms such as anxiety and depression" (p. In response to Frances’s statement that the "monkey in the middle" was me, I approached the mural as it hung on the wall and said, "So that’s me? Frances, could it be that you’re worried that if I did enter, I’d find things to be critical of? Paired Communication Drawing Overall, psychodynamic family art therapy unites symbolic communi- cation with concepts related to transference reactions, the interpretation of individual as well as shared defenses, issues related to maturation, resis- tance, responses to inner conflict, and unconscious motivations. The pro- cess of communication can be enhanced by the implementation of art therapy directives as the family works toward productive ways of interact- ing.

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Finally discount kamagra gold 100mg without prescription erectile dysfunction pump ratings, let us take a critical look at hierarchies in medicine and the ordeal theory of medical education buy kamagra gold 100mg cheap impotence definition inability. Medical training is difficult enough without unnecessary shaming and humiliation for the trainees, and without subjecting them to impossible hours and patient loads, especially, at times, without adequate supervision and help from attending physicians. With the entry of women into medicine and a little help from the nascent efforts of medical residents to bargain on their contracts, some earlier abuses have been mitigated. And of course, there are vast differences between the various programs, with some being collegial and others completely authoritarian. But too often, the graduate of a training program which resembles boot camp, who has survived unnecessary hazing and servility, now thinks of him or herself as better than others and somehow deserving of special honor and recompense. But that is the very attitude that gives physicians the reputation of arrogance and greed with the general public. In the name of the humility we need and not humiliation which is compensated later by pomposity, the schools, by example as well as precept, should teach mutual respect and cooperation. Collegiality also means sharing of knowledge, not thinking of it as something which should be anyone’s private property. Some senior physicians share knowledge freely with students, patients and other caregivers. Instead of rattling off the legal minimum to obtain "informed consent" from patients, they engage in teaching and learning give and take. Instead of intimidating students by ridiculing their ignorance they encourage and value questions. Instead of withholding secret and esoteric knowledge in an attempt to impress nurses and other team members with their own significance or that of their specialty, they enjoy enlightening and empowering others. Instead of clinging to the small comfort of being special through separation, they have the great comfort of honoring and nurturing common humanity. The Course of Medical Care It would be wise, in order to locate our medical encounters properly in lives, to ask patients whenever possible, an open ended question such as "What is going on in your life right now? In addition, as often suggested, but more often honored in the breach than in the observance, we should give most patients a few minutes to give a freewheeling, unstructured account of their problems. People like to tell a story, and they like to think their stories are worth hearing. It is very difficult to bond with a caregiver who starts right out managing the way you tell your tale. Doctors are not usually well taught the elemental fact that communication is a two way street. The specific, very useful and very structured medical history can afford to wait a bit, in most circumstances, while the patient gets a little off his chest. Then, the caregiver must look for the uniqueness and interest in every situation, as well as the features it has in common with others. And the caregiver must be attuned to what the patient is ready to hear, FULL SPECTRUM MEANS AND ENDS REASONING 165 and not go on like a tape recorder just to prove to a later chart reviewer that advice (even though counterproductive and not worthwhile for this patient this time) was complete. In other words, we cannot hold ourselves rigidly to routine advice about "procedures, alternatives and risks" simply to look good on paper, but must tailor all our comments to the people and the circumstances. There is no insurance or health maintenance administration, and no government review process which can, given current assumptions, measure the real value of the "product" of care. And the quality of treatment and results for any one condition does not necessarily correlate with the overall quality when patients have multiple conditions and concerns. So, if we are going to assess results we need to take a much more sophisticated and complete view of what those are than we have done using narrowly focused snapshots. Administrators have decided that they can reform and revolutionize care by imposing industrial methods of production and evaluation on professionals. However, they usually do not bother to find out the reasons why things are as they are, and they do not want to hear what caregivers have to say about the adminis- trative initiatives. However, everyone knows that caregivers have not resisted drastic changes resulting from advances in medical science and technology. There is resistance based on the real inappropriateness of the industrial model, and based on the fact that the industrial initiatives are imposed by administrations rather than grown organically out of practice. Physicians are letting computers, both literally and figuratively, come between them and their patients. Furthermore, time is of the essence, but this does not always mean that haste saves time in the long run. It is better to spend a longer time on one visit actually listening to the patient, addressing at least some problems adequately, and eliciting a good chance of understanding and compliance, than to do a superficial job in haste, generating numbers for the administrators and shekels in the till, but failing to make real progress. And speaking of shekels in the till as well as monetary measures of production, physicians in general charge too much. Illness should not be the reason for major wealth transfer from the sick to their caregivers.

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A further advantage is that circuits offer variety kamagra gold 100mg low cost erectile dysfunction nursing interventions, and each station can be adapted to allow for individual ability 100mg kamagra gold mastercard erectile dysfunction statistics, thus allowing progression both within and between stations. In addition, they provide motor skills development and include more functional- type exercise. Furthermore, circuits are an opportunity for social interaction amongst participants and, because the exercise leader is not required to exer- cise, he or she is free to move around participants and to provide individual coaching and correction. Finally, depending on the type of circuits created, they can be used as a model for home-based exercise. Home-based exercise circuits can be delivered as a video or using copies of the stations on the Physiotools package (2005) with a created handout of individual exercises. Factors to Consider in Circuit Design Careful planning and preparation, knowing in advance the limitations on room size, equipment available, number of participants, etc. In general the circuit must follow in a logical sequence with an easy-to-follow plan. This becomes more important especially Class Design and Use of Music 137 with larger groups and with participants of different levels of exercise ability, for example, from very deconditioned to above average fitness. Your circuit needs to have a sufficient number of stations to accommodate all the participants, along with sufficient trained staff to supervise those exercising. Current Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR, 2003) guide- lines recommend a staff-to-patient ratio of 1: 5. If you are planning to use exercise equipment you will have to make sure there is enough available to prevent queuing as participants wait for equipment to become available. Above all you need to ensure that the circuit consists of ade- quate aerobic-type exercises (see Table 5. Examples of aerobic exercise Leg Pattern Arm Pattern Knee lifts Elbow bends Toe taps behind Double punch forwards Toe taps to side Side arm raises Knee bends Butterfly (pectoral) Back heel lifts Criss-cross to front Three steps forwards and back Arm raise above head Side lunges Hand push-downs Heel digs to front Reach pull back March Forward elbow circles Two steps to side and back Low swing behind back Step kicks Diagonal arm reaches Toe taps to front Forward arm swing Table 5. Aerobic exercises involve rhythmic movement of large muscle groups involving the whole body. Variations in the starting position of an upper body exercise can have a significant effect on rate pressure product (RPP). For example, elbow flexion and extension performed with the arms by the side are easier than when the arms are held at shoulder level, which is easier than when the arms are held high above the head. When selecting individual exercises, it is essential to ensure there is a balance of exercise on different muscle groups, and that consecutive exercises do not result in overusing any one muscle group (e. Active recovery stations, by their very nature, need to be evenly spaced amongst the aerobic stations and not next to one another. AR exercise involves a muscle to exert sub-maximal forces against a resistance over an extended period of time and differs from strength. Musculoskeletal endurance (MSE) is best developed by using lighter weights and with a greater number of repetitions (Pollock, et al. As a rule for muscular endurance, select resistances that allow more than 16 repetitions to be performed without induc- ing fatigue (i. If muscular endurance exercises are chosen, then they should target muscles not used extensively in the CV component (see Table 5. Examples of muscular endurance exercises Muscle/group Exercise Gastrocnemius Standing single calf raises Gluteals Standing single hip extension Upper trapezius and deltoid Upright row holding weighted pole Lateral dorsi and rhomboids Seated row with elastic band Triceps Standing press backs or seated dips Gluteal medius and minimus Standing hip abduction Biceps Bicep curls holding dumbbells Lateral rotator cuff Seated shoulder rotations with elastic band Quadriceps, hamstrings and gluteal Wallslides maximus Pectorals and triceps Chest press (band around back under arms) Class Design and Use of Music 139 Station 1 Station 2 Station 3 Station 4 Station10 Station 9 Station 5 Station 8 Station 7 Station 6 Figure 5. Room Arrangement In its basic format, a circuit is usually arranged around the perimeter of the room (see Figure 5. Alternative layouts, which may better suit the dimensions of the exercise room, are shown in Figures 5. Using different room arrangements pro- vides variety, while still using the same stations. Often circuit classes are held in physiotherapy departments, where other equipment is stored. This is helpful when there are several beginners in the class as it keeps it simple for both the participants and the instructor. One group goes round the perimeter stations in a clockwise direction, while the other group goes round the perimeter stations in an anticlockwise direction. This means that participants exercise with a different person at each station, rather than going round the whole circuit with the same person. This can be a useful way of getting the group to mix and it can promote better self-pacing and less competiveness, since the exercise partner is constantly changing. The line at the far end (line E) will not be able to 140 Exercise Leadership in Cardiac Rehabilitation Stations 1 and 2 Stations 5 and 6 Stations 3 and 4 Stations 9 and 10 Stations 11 and 12 Stations 7 and 8 Figure 5. After all five exer- cises have been completed the exercise leader gets the group to perform an active recovery walk and then changes the line exercise for the second circuit. This circuit relies on at least one participant in each group acting as a line leader. Station Duration Aerobic stations can vary between 30 seconds and three minutes, with the duration dictated by participants’ functional capacity. Least fit participants will Class Design and Use of Music 141 Stations 3 and 4 Stations Stations 1 and 2 5 and 6 Stations 7 and 8 a Stations 2 and 6 Stations Stations 1 and 5 3 and 7 Stations 4 and 8 b Figure 5. The time between consecutive stations should be kept to a minimum, and, as a guide, should only last long enough for participants to walk from one station to the next.

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