The subjects were encouraged to use distraction tech- niques to reduce depression and pain perception duloxetine 30 mg with visa. They were encouraged to shift their focus from those activities they could no longer perform to those that they could enjoy buy 40 mg duloxetine overnight delivery. Activity goals were scheduled and pleasant activities were reinforced at subsequent groups discount duloxetine 60mg otc. Time 1 to time 2 The results showed significantly different changes between the two groups in all their ratings effective duloxetine 20mg. Compared with the control group, the subjects who had received cognitive behavioural treatment reported lower pain intensity, lower functional impairment, better daily mood, fewer bodily symptoms, less anxiety, less depression, fewer pain-related bodily symptoms and fewer pain-related sleep disorders. Time 1 to time 2 to time 3 When the results at six-month follow-up were included, again the results showed sig- nificant differences between the two groups on all variables except daily mood and sleep disorders. The role of adherence The subjects in the treatment condition were then divided into those who adhered to the recommended exercise regimen at follow-up (adherers) and those who did not (non-adherers). The results from this analysis indicate that the adherers showed an improvement in pain intensity at follow-up compared with their ratings immediately after the treatment intervention, whilst the non-adherers ratings at follow-up were the same as immediately after the treatment. Conclusion The authors conclude that the study provides support for the use of cognitive– behavioural treatment for chronic pain. The authors also point to the central role of treatment adherence in predicting improvement. They suggest that this effect of adherence indicates that the improvement in pain was a result of the specific treatment factors (i. However, it is possible that the central role for adherence in the present study is similar to that discussed in Chapter 13 in the context of placebos, with treatment adherence itself being a placebo effect. Placebos and pain reduction Placebos have been defined as inert substances that cause symptom relief (see Chapter 13). Beecher (1955) suggested that 30 per cent of chronic pain sufferers experience pain relief after taking placebos. A sham heart bypass operation involved the individual believing that they were going to have a proper operation, being prepared for surgery, being given a general anaesthetic, cut open and then sewed up again without any actual bypass being carried out. The individual therefore believed that they had had an operation and had the scars to prove it. However, the results suggested that angina pain can actually be reduced by a sham operation by comparable levels to an actual operation for angina. This suggests that the expectations of the individual changes their perception of pain, again providing evidence for the role of psychology in pain perception. The psychological treatment of pain includes respondent, cognitive and behavioural methods. These are mostly used in conjunction with pharmacological treatments involving analgesics or anaesthetics. The outcome of such interventions has tradition- ally been assessed in terms of a reduction in pain intensity and pain perception. Recently, however, some researchers have been calling for a shift in focus towards pain acceptance. This methodology encourages the participant to describe their experiences in a way that enables the researcher to derive a factor structure. From their analysis the authors argued that the acceptance of pain involves eight factors. These were taking control, living day-by-day, acknowledging limitations, empowerment, accepting loss of self, a belief that there’s more to life than pain, a philosophy of not fighting battles that can’t be won and spiritual strength. In addition, the authors suggest that these factors reflect three underlying beliefs: (i) the acknowledgment that a cure for pain is unlikely; (ii) a shift of focus away from pain to non pain aspects of life; and (iii) a resistance to any suggestion that pain is a sign of personal weakness. In a further study McCracken and Eccleston (2003) explored the relationship between pain acceptance, coping with pain and a range of pain-related outcomes in 230 chronic pain patients.

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Examples of the factors that support the dehydration generic duloxetine 30 mg line, 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 generic duloxetine 40mg with amex, 1995) order duloxetine 60 mg with amex. Accurately as- Maintenance of stability lines are penetrated in both reaction sessing the effects and possible effects and reconstitution phases of environmental stressors (inter- purchase 30 mg duloxetine fast delivery, 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. Neuman cluding the basic structure of energy factors toward views health as a manifestation of living energy system integration, stability, and integrity to create available to preserve and enhance system integrity. This safe, created environment Health is seen as varying levels within a normal offers a protective coping shield that helps the range, rising and falling throughout the life span. A major objective of the created These changes are in response to basic structure environment is to stimulate the client’s health. The created envi- Nursing is the fourth concept in Neuman’s model ronment supersedes or goes beyond the internal and is depicted in Figure 18–4. The created environment provides an insulat- Nursing’s major concern is to keep the ing effect to change the response or possible re- client system stable by (1) accurately sponse of the client to environmental stressors. Neuman outcome of the created environment (extent of its defined optimal as the best possible health state use and client value), and (3) the ideal that has yet achievable at a given point in time. Nursing actions, to be created (the protection that is needed or pos- which she labels as prevention by intervention, are sible, to a lesser or greater degree). Neuman has cre- is necessary to best understand and support the ated a typology for her prevention by intervention client’s created environment (Neuman, 1995). They include primary prevention Neuman suggested that nursing may wish to pur- by intervention, secondary prevention by interven- sue and further develop an understanding of the tion, and tertiary prevention by intervention. Neuman pointed out that one or among the client, the environment, health, and all three of these prevention modalities give direc- nursing in the process of keeping the system stable. These formats are presented in the third stressor is suspected or identified, before a reaction edition of Neuman’s book (1995, pp.

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Successful reproduction in humans involves the coordination of a wide variety of behaviors purchase duloxetine 40mg with mastercard, including courtship order 30 mg duloxetine with amex, sex discount duloxetine 40 mg otc, household arrangements buy duloxetine 20 mg online, parenting, and child care. The Experience of Sex The sexual drive, with its reward of intense pleasure in orgasm, is highly motivating. The [26] biology of the sexual response was studied in detail by Masters and Johnson (1966), who monitored or filmed more than 700 men and women while they masturbated or had intercourse. Masters and Johnson found that the sexual response cycle—the biological sexual response in humans—was very similar in men and women, and consisted of four stages: Excitement. Women‘s breasts and nipples may enlarge and the vagina expands and secretes lubricant. Muscular contractions occur throughout the body, but particularly in the genitals. The spasmodic ejaculations of sperm are similar to the spasmodic contractions of vaginal walls, and the experience of orgasm is similar for men and women. The woman‘s orgasm helps position the [27] uterus to draw sperm inward (Thornhill & Gangestad, 1995). After one orgasm, men typically experience a refractory period, in which they are incapable of reaching another orgasm for several minutes, hours, or even longer. The sexual response cycle and sexual desire are regulated by the sex hormonesestrogen in women and testosterone in both women and in men. Although the hormones are secreted by the ovaries and testes, it is the hypothalamus and the pituitary glands that control the process. Estrogen levels in women vary across the menstrual cycle, peaking during ovulation (Pillsworth, [28] Haselton, & Buss, 2004). Women are more interested in having sex during ovulation but can experience high levels of sexual arousal throughout the menstrual cycle. In men, testosterone is essential to maintain sexual desire and to sustain an erection, and testosterone injections can increase sexual interest and performance (Aversa et al. Women who are experiencing menopause may develop a loss of interest in sex, but this interest may be rekindled through estrogen and testosterone replacement treatments (Meston & Frohlich, [30] 2000). Although their biological determinants and experiences of sex are similar, men and women differ substantially in their overall interest in sex, the frequency of their sexual activities, and the mates they are most interested in. Men show a more consistent interest in sex, whereas the sexual [31] desires of women are more likely to vary over time (Baumeister, 2000). Men fantasize about sex more often than women, and their fantasies are more physical and less intimate (Leitenberg Attributed to Charles Stangor Saylor. Men are also more willing to have casual sex than are women, and their [33] standards for sex partners is lower (Petersen & Hyde, 2010; Saad, Eba, & Sejean, 2009). Gender differences in sexual interest probably occur in part as a result of the evolutionary predispositions of men and women, and this interpretation is bolstered by the finding that gender [34] differences in sexual interest are observed cross-culturally (Buss, 1989). Evolutionarily, women should be more selective than men in their choices of sex partners because they must invest more time in bearing and nurturing their children than do men (most men do help out, of [35] course, but women simply do more [Buss & Kenrick, 1998]). Because they do not need to invest a lot of time in child rearing, men may be evolutionarily predisposed to be more willing and desiring of having sex with many different partners and may be less selective in their choice of mates. Women, on the other hand, because they must invest substantial effort in raising each child, should be more selective. The Many Varieties of Sexual Behavior Sex researchers have found that sexual behavior varies widely, not only between men and women but within each sex (Kinsey, Pomeroy, & Martin, 1948/1998; Kinsey, [36] 1953/1998). About a quarter of women report having a low sexual desire, and about 1% of people report feeling no sexual attraction whatsoever (Bogaert, 2004; Feldhaus-Dahir, 2009; [37] West et al. For about 3% to 6% of the population (mainly men), the sex drive is so strong that it dominates life [38] experience and may lead to hyperactive sexual desire disorder(Kingston & Firestone, 2008). There is also variety in sexual orientation, which is the direction of our sexual desire toward people of the opposite sex, people of the same sex, or people of both sexes. The vast majority of human beings have a heterosexual orientation—their sexual desire is focused toward members of the opposite sex. Another 1% of the population reports being bisexual (having desires for both sexes).

Nursing Situation Nursing Response The practice of nursing duloxetine 20mg overnight delivery, and thus the practical knowledge of nursing generic 20 mg duloxetine with amex, lives in the context of As an expression of nursing cheap 40 mg duloxetine otc, “caring is the inten- person-with-person caring order duloxetine 60 mg without prescription. The nursing situation tional and authentic presence of the nurse with an- involves particular values, intentions, and actions other who is recognized as living caring and of two or more persons choosing to live a nursing growing in caring” (Boykin & Schoenhofer, 1993, relationship. The nurse enters the nursing situation with mean the shared lived experience in which caring the intentional commitment of knowing the other between nurse and nursed enhances personhood. All knowl- edging, affirming, and celebrating the person as edge of nursing is created and understood within caring. Any single nursing situation sion of caring nurturance to sustain and enhance has the potential to illuminate the depth and com- the “other” as he or she lives caring and grows in plexity of nursing knowledge. Nursing re- are best communicated through aesthetic media to sponses to calls for caring evolve as nurses clarify preserve the lived meaning of the situation and the their understandings of calls through presence and openness of the situation as text. Sensitivity and skill in creating unique and effective ways of communicating caring are devel- His eyes meet mine, oped through intention, experience, study, and Unable to speak, reflection in a broad range of human situations. It is the loving relation into which nurse Our bond is made, Unspoken thoughts, But understood, The caring between is the source and I care for him! Collins (1993) and nursed enter and cocreate by living the inten- Each encounter—each nursing experience— tion to care. In Collins’s reflections, ing between, unidirectional activity or reciprocal he shares a story of practice that illuminates the exchange can occur, but nursing in its fullest sense opportunity to live and grow in caring. It is in the context of the caring be- In the nursing situation that inspired this poem, tween that personhood is enhanced, each express- the nurse and nursed live caring uniquely. This al- particular experience of nursing and linked to a lows him to see past the “anger-filled” room and to general conception of nursing. By living caring moment to moment, hope emerges and fear My hands are moist, subsides. Through this experience, both nurse and My heart is quick, nursed live and grow in their understanding and My nerves are taut, expressions of caring. He’s in the next room, In the first stanza, the nurse prepares to enter the I care for him. Perhaps he It’s anger-filled, has heard a report that the person he is about to en- The air seems thick, counter is a “difficult patient,” and this is a part of I’m with him now, his awareness; however, his nursing intention to I care for him. In the second stanza, the nurse Time goes slowly by, enters the room, experiences the challenge that his As our fears subside, intention to nurse has presented, and responds to I can sense his calm, the call for authentic presence and caring:“I’m with He softens now, him now/I care for him. The nurse listens intently and the College of Nursing at Florida Atlantic recognizes the unadorned honesty that sounds University, where both authors were among the fac- angry and demanding but is a personal expression ulty group revising the caring-based curriculum. The nurse responds with steadfast presence us recognized the potential and even the necessity and caring, communicated in his way of being and of continuing to develop and structure ideas and of doing. The caring ingredient of hope is drawn themes toward a comprehensive expression of the forth as the man softens and the nurse takes notice. The point of departure was the ac- ops, and personhood is enhanced as dreams and as- ceptance that caring is the end, rather than the pirations for growing in caring are realized: “His means, of nursing, and that caring is the intention eyes meet mine... This stanza, the nursing situation is completed in linear work led to the statement of focus of nursing as time. But each one, nurse and nursed, goes forward, “nurturing persons living caring and growing in newly affirmed and celebrated as caring person, and caring. The clarified focus and the idea of the nurs- In Collins’s poem, the power of the basic assump- ing situation are the key themes that draw forth the tion that all persons are caring by virtue of their meaning of the assumptions underlying the theory humanness enabled the nurse to find the courage to and permit the practical understanding of nursing live his intentions. As critique of and complete in the moment permits the nurse to the theory and study of nursing situations pro- accept conflicting feelings and to be open to the gressed, the notion of nursing being primarily con- nursed as a person, not merely as an entity with a cerned with health was seen as limiting, and we diagnosis and superficially or normatively under- now understand nursing to be concerned with stood behavior. Person- human mode of being was incorporated into the hood, a way of living grounded in caring that can most basic assumption of the theory. We view be enhanced in relationship with caring other, Paterson and Zderad’s (1988) existential phenome- comes through in that the nurse is successfully liv- nological theory of humanistic nursing as the his- ing his commitment to caring in the face of diffi- torical antecedent of nursing as caring. Seminal culty and in the mutuality and connectedness ideas such as “the between,” “call for nursing,” that emerged in the situation. Schoenhofer’s Nursing as Caring Theory 339 substantive and structural bases for our conceptu- ment and surveillance techniques. Mayeroff’s (1971) that is an insufficient response—it certainly is not work, On Caring, provided a language that facili- the nursing we advocate.

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