Healthcare professionals, roles and virtue

Mrs. J. is a 76-year-old woman who had been in good health. When she was brought to the hospital 10 days after being involved in an automobile accident, she was found to have severe brain injury and, despite vigorous treatment, has never regained consciousness. The consulting neurologist feels that she has no chance to recover completely and the "best case scenario" is that she may regain some consciousness without ever being able to take care of herself or probably without ever being able to interact with her environment in a meaningful fashion. She and her husband have been very close and had just celebrated their 50th wedding anniversary when the accident occurred. After long deliberation, her husband states that his wife had often said that "she would never want to live like this" and that she had always had a fear of being a burden to anyone. He wants active treatment stopped and asks that she only be kept comfortable and allowed to die. Their daughter agrees with this decision, although their son who lives in a distant state, feels that all treatment should continue and that she "certainly wouldn't be a burden." Among other considerations brought up by the husband is the fact that there are no financial arrangements to take care of long-term care in a nursing home.     

Contraception--a woman's dilemma

The case history of a 36-year-old West German woman--Elsa--who had an abortion is recounted along with information obtained from other members of staff involved with her care--a medical social worker, a family planning nurse, and a doctor. Conversation with Elsa revealed that she had ambivalent feelings about birth control. When Elsa learned she was pregnant, she seriously considered her subsequent decision to have an abortion. Actually, she would have preferred to have the baby if she could have depended on her boyfriend's encouragement and his commitment to being a father. At the clinic, Elsa was found to be in good physical condition. She informed the doctor that she had already had 2 terminations of pregnancy, 15 and 11 years ago. Following the birth of her son she had taken an oral contraceptive (OC) for 4 years, but had stopped taking it in 1976 because she thought she was too old for the pill and had been taking it too long. She had then used an IUD, but this had supposedly been removed 10 weeks before the abortion, after she had suffered from recurrent menorrhagia and heavy vaginal discharge. Elsa was then fitted with a diaphragm which she had been using when she became pregnant. After the abortion, Elsa continued to be undecided about what form of contraception to use in the future. She did not want to become pregnant again before she was in a position to have the baby. Elsa had good reason for concern about using OC, i.e. OCs containing estrogen and progestogen, at the age of 36. Along with discussion about the use of OC, Elsa sought more information about the diaphragm. Elsa finally decided to use OCs, but it is doubtful if she will ever be content with either this method or the diaphragm. Family planning nurses have an important role to play in educating people about contraceptives and their use, but they should never tell people that they should or should not be controlling their fertility.     

Peanut allergy: an increasing health risk for children

Matthew, age 24 months, is brought into the clinic by his frantic mother. She reports Matthew started wheezing and broke out in a blotchy skin rash within 5 minutes of eating a cracker with peanut butter. Matthew has a history of mild, intermittent asthma treated with nebulized albuterol, which the mother administered without improvement in the child's breathing pattern. He also has a history of moderate atopic dermatitis and a prior milk intolerance that he has since outgrown. No other food allergies are noted in his history, and the mother believes this is the first time Matthew has eaten peanut butter. It has been approximately fi hour since he ingested the peanut butter. Matthew's vital signs are temperature 98.6 degrees F, pulse 90, and respirations 60 with audible wheezing and repetitive cough. His blood pressure is 80/60. His face and chest are flushed with urticaria, and some swelling is noted around his mouth.     

The culture of adversity: youth in foster care

Nannette, age 7, has been in and out of foster care since birth. Recently, Nannette was referred to the clinic because she complained of burning "down there." When you examine her you find a scar through the posterior fourchette and vestibule. She begins to cry and pleads with you not to hurt her.     

Traditional Chinese medicine: a case of dysmenorrhoea

Acupuncture treatment continued for three cycles, undertaken one week prior to menses whereas herbal therapy was maintained for six months. Within this six month time frame Jenny's overall health status had changed dramatically for the better. She was pain free and consequently her life-style had improved to the point where she felt confident to travel overseas for a holiday. To date, Jenny and her mother have kept in touch with clinic staff and no further treatment has been necessary.     

Drug-facilitated sexual assault: educating women about the risks

"Andrea," an 18-year-old college freshman, walked into her first fraternity party with a few of her sorority sisters. As she walked through the crowded house, one of the fraternity boys handed the girls large plastic cups. Another boy circulated through the crowd, filling up the cups of all guests from two pitchers of beer. When he filled Andrea's cup, he smiled and was polite and charming. She thought his act of filling her cup was kind and gentlemanly, and was flattered by his attention. She didn't notice he used a different pitcher for her than he had for her friends. She and her friends continued to mill through the crowd, sipping their beer. About 20 minutes later, Andrea suddenly had trouble focusing her vision. She felt disoriented and "drunk" even though she had only consumed a third of her beer. She started feeling nauseated, and tried to find her friends. The polite boy who had poured her beer asked her if she was all right, and offered to take her up to his room so she could rest. She followed him, grateful to be able to lie down. Forty-five minutes later, her concerned friends searched the house for Andrea. They found her upstairs passed out in a bedroom, lying on her side; she had vomited and her clothes were disheveled. Suspecting only alcohol intoxication; they picked her up, and walked her out of the party. After Andrea slept for about two hours, she woke up and told her friends something wasn't right. She had only drunk a small amount of her beer, and had no recollection after she walked up the stairs with the boy. She burst into tears, stating she feels some vaginal discomfort, and is afraid she may have been raped. Her friends looked at each other, thinking, "How did this happen and what are we supposed to do?"     

Osteogenesis imperfecta in adults

A 42-year-old premenopausal woman with osteogenesis imperfecta presents to the metabolic bone clinic. She has a daughter with osteogenesis imperfecta who is seen regularly in a specialist pediatric clinic, but the patient herself hasn’t had a clinical consultation in years. She has pain and stiffness in her back and is worried for her future bone health. The patient asks, “Am I going to fall apart?” She had numerous fractures in childhood, including fractures of her femur and wrist; fractured her ankles several times in her late teens; and had occasional fractures in adulthood. Her last fracture was a comminuted fracture of her humerus three years ago, when she stumbled and fell forward onto her hands and knees. The woman is hyperextensible and thinks her ankles feel weak. Her bone mineral density T scores are –2.6 at the lumbar spine and –1.9 at the total hip, and spine imaging shows several vertebral endplate deformities, but overall preservation of vertebral height. What are the available pharmacological and nonpharmacological strategies to preserve her skeletal health and function?Osteogenesis imperfecta (OI) is the most common inherited disease that causes bone fragility, occurring with a frequency of 1 in 5,000 to 1 in 10,000 births (1). The majority of OI patients (85%–90%) have mutations in the genes encoding type I collagen; however, over the last ten to fifteen years, defects in genes encoding proteins involved in collagen processing, folding, and stability as well as in osteoblast differentiation or function have also been described (2). Patients with milder forms of OI generally have normal collagen, albeit in reduced quantities, while patients with more severe forms generally have abnormal collagen, collagen metabolism defects, or osteoblast-related pathway abnormalities. The degree of bone fragility ranges from apparently mild, with occasional fractures and minimal effects on bone shape or length, to severe, progressively deforming disease with many fractures, which can exceed 200 fractures during childhood. Severe bone fragility can be lethal in utero (multiple rib fractures can result in failure of lung development, and the abnormal skeleton can fail to protect internal organs, including the brain) or later in life (due to the effects of scoliosis or the invagination of the odontoid peg into the brain stem). Patients with such conditions undergo multiple corrective surgical procedures, with most individuals experiencing bone pain, reduced mobility, and below-average stature; severely affected individuals are very short. Ligamentous laxity can also be a prominent feature, exacerbating pain and mobility problems. Dentinogenesis imperfecta can result in teeth chipping and cracking, accelerated dental decay, and tooth loss. Patients with severe OI can also experience hernias, heart valve prolapse, and mixed conductive and sensorineural hearing loss, which all increase in frequency with age.     

Emergency department presentation of ‘delusional parasitosis by proxy’. Delusional parent,injured child

We report a case of 'delusional parasitosis by proxy'. A sixyear old child was brought to the emergency department by a mother with concerns that her son had a skin and scalp infestation. Despite the absence of any clinical findings being found on exam, the mother remained disproportionately concerned. Follow up care was recommended with the child's primary care. The mother returned to the ED with her child three weeks later with concerns that her son had an inflamed scalp and eyes. The mother remained insistent that the child was infested with bugs and she had sought care at two other locations where the child was prescribed permethrin on both visits. She had been applying the medication repeatedly. On exam the boy's scalp had been shaved and was erythematous and irritated; his eyebrows and eyelashes had also been shaved off and likely contributed to an irritant conjunctivitis from repeated applications of topical permethrin lotion. No evidence of infestation was identified. We recruited the assistance of the maternal grandparents, child protective services and primary care pediatrics and the child was removed from the mother's custody and placed into the custody of the grandparents. Six weeks later with basic skin care and erythromycin ophthalmic ointment for the eyes, the child's hair, eyebrows and eyelashes grew had grown in, and the scalp irritation had resolved. The mother had sought and received psychiatric care and was improving.     

Reproductive Decision-Making in the Age of AIDS

The forecast for the HIV epidemic in the United States includes increasing numbers of infected women and children, the latter of whom will be born to infected mothers. As the epidemic progresses, nurses will be more frequently called on to assist women in making difficult reproductive decisions. Using four levels of analysis, this discussion explores current knowledge about reproduction in HIV-infected women and suggests interventions and nursing actions.
Beth is a 32-year-old mother with a history of drug use. She was tested for the HIV when she was 8 months pregnant at the urging of her sister. She was surprised when the test was positive and unprepared for the events that followed: abandonment by her obstetrician, delivery at a strange hospital, and isolation on the post-partum unit. Her 5-year-old son is not infected .
Carmen, now 17 years old, was infected with HIV through sexual activity at age 14. When she became pregnant at 16, her doctor told her not to have the baby. Despite religious convictions and personal desires, she had an abortion. She says, "That may have been my only chance to have a baby and now it's gone."     

Florence Nightingale: Appreciating our legacy, envisioning our future.

"If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music that he hears, however measured or far away." This quote is attributed to Henry David Thoreau, (Walden, 1854) not Florence Nightingale, but it certainly can describe Florence, particularly in early life. Florence, you can say, "had it all": wealth, education, a doting extended family, and a life of leisure, which included the opportunity to travel anywhere in the world. Even her name was given because she was born in Florence, Italy, during her parents' 3-year honeymoon tour of Europe. But inside Florence, "the different drummer" quietly but steadily beat, and her life was compelled to seek until she could find or, in her case, create the music she heard. After years of searching, Florence determined that "nursing," a practice every woman engaged in, was not simply a matter of kindness and care, but rather a body of knowledge, an art and a science. She never lost sight of her goal that nursing should become a profession in its own right, and not a branch of medicine. Nursing at that time was reserved for nuns in Germany, Ireland, and France, or for family and friends caring for relatives who were ill. Florence felt nursing was her "calling" and her mission. Once she discovered nursing, she pursued it for more than 50 years until the last moment of her life. Her dedication has a good deal to do with how and why we are nursing today.     

Bereavement: helping a patient with a learning disability to cope

Our case study is of a 55-year-old man who has a moderate learning disability. He has been diagnosed as having bipolar disorder and is currently in remission. At Christmas six years ago while Dave Croft was on home leave from an NHS unit, his father died suddenly. His mother, acting in what she felt were Mr Croft's best interests, arranged the funeral and did not inform her son until after the ceremony had taken place. Mr Croft appeared to have adjusted to his loss, until November 2001 when he became increasingly upset and agitated at the mention of death. A multidisciplinary team approach and the use of a 'life event book' helped Mr Croft come to terms with his bereavement and allowed staff at the unit to put a strategy in place to help him prepare for future family bereavements.     

Legal aspects of consent 16: statutory provisions and living wills

Case Scenario: Mary had cared for her invalid mentally infirm mother for many years and was determined that if she ever lost her own mental capacity she would not wish to be kept alive. She drew up a document, witnessed by her sister, that stated in the event of her suffering from any form of mental incapacity she would not wish to be fed or have any medical or nursing intervention. Some years later she began to suffer from the early signs of Alzheimer's disease. Her sister had died, but staff were aware that Mary still carried this living will on her person. She is now refusing all food. What is the law?     

The death of Sadie Sachs

Helplessly watching a woman die from a self-induced abortion forever changed the life of Margaret Sanger, the women who brought the issue of birth control to the forefront of feminist and health issues. In 912, Sanger, wide and mother of 3, practiced nursing in New York City. One day she accompanied a physician to an emergency at the house of Jake Sachs, a 28 year-old truck driver and husband of Sadie Sachs. Sadie was very ill, the product of a self-induced abortion. Sanger nursed Sadie for several weeks until she recovered, but as Sanger prepared to make her leave, Sadie said that another pregnancy would end her life. Sanger asked the physician if there was anything that could be done, but he responded negatively. Three months later, the Sachs household had another emergency, and Sanger promptly arrived, already knowing what she would find. It was too late to save Sadie Sachs. This incident changed her life. She renounced the nursing profession for activism, but was unable to convince her feminist and socialist friends of the need for controlling family size. So she began studying all there was to know on the subject, and came to coin the term "birth control". Later she started publishing a magazine designed to educate on birth control, but the authorities put an end to it, since the law prohibited anyone from providing information to prevent conception for any reason. She fled to England, but returned to open a clinic in Brooklyn that distributed information on birth control. The clinic served hundreds of people, until it was raided by police on the 9th day of operation. Sanger went to jail. Nonetheless, her pioneering efforts did begin the acknowledgement of the need for birth control. And now, public opinion stands on the side of Margaret Sanger.     

VULNERABILITY FACTORS IN SYLVIA PLATH'S SUICIDE

Using the conceptual framework of a developmental pathway , this study links together events in the life of Sylvia Plath , beginning with her father's death when she was 8years old and ending with her suicide at age 30 . Unresolved grief for her father led to a symbiotic attachment to her mother characterized by a compulsive drive for achievement and praise . After a near - fatal suicide attempt at age 20 following failure to meet perfectionistic ideals , she recompensated , transferring her dependency needs into a symbiotic marriage to an English poet she narcissistically idealized . Her suicide followed soon after the collapse of the marriage . Emphasis is placed throughout on her unwillingness to accept personal imperfections , as well as on the search for a father substitute .     

Legal regulation mechanisms in the control of medicines

In 2002, a case was brought against the Secretary of State--sued on behalf of the Committee for the Safety of Medicine (CSM)--by a mother who in May 1986 gave aspirin to her 6-year-old daughter who was suffering from chickenpox (Smith vs. Secretary of State for Health, [2002]). The child deteriorated and following admission to hospital she was diagnosed as suffering from Reye's syndrome. As a consequence, the girl was left with a serious neurological handicap and was totally dependent on others for her care. In June 1986, the government issued a general public warning advising parents not to give aspirin in any form to children under 12 years old and told chemists to take all junior aspirin preparations off their shelves. This followed advice from the CSM that in this age group aspirin could trigger the fatal disease Reye's syndrome. The CSM had been aware of this danger in September 1982 following evidence in the USA. Further evidence was produced in 1985 and the CSM continued to monitor the situation. In April 1986, a meeting was held between the Department of Health (DoH) and members of the aspirin industry. It was subsequently agreed that the producers would withdraw stocks and there would be cooperation between the industry and the DoH rather than a public warning. In May 1986, the CSM recommended that the DoH should give a general public warning, which was made on 10 June 1986. The mother's case was that there was an unreasonable delay in publishing a warning following the CSM meeting on 26 March 1986. It was accepted that the administration of aspirin was a contributory factor in the development of the girl's neurological condition and that had her mother been aware of the warnings before May 1986 she would not have given her aspirin. Were the Secretary of State and CSM liable?     

Confidentiality. 14: Powers of the police and access to information

Staff nurse Paula Rose was on duty in the accident and emergency (A&E) department early one Sunday morning when a police constable came in asking for details of any patient who had been brought in and for whom there was evidence of a fall from height. The constable explained that a girl had been assaulted and raped while in her bedroom by an assailant who came in through the window. Her screams brought help, but he made his escape from the window and she believed that he had fallen and may have suffered fractures or bruises.     

治疗技术和方法

exploration of vertebral canal 椎管探查术 section of sensory root of trigeminal nerve 三叉神经感觉根切断术 ventriculo-peritoneal shunt 脑室腹腔引流术     

Talking theory, talking therapy: Emmy Gut and John Bowlby

Emmy Gut was a psychotherapist who developed, in her later years, a unique theory distinguishing between "productive" and "unproductive" depression. Dr. John Bowlby was a leading psychoanalyst famous for his work on attachment theory. After the death of her second husband, Emmy contacted John because his work on mourning and grief spoke to her own depressed state. Although her views of the world and of her relationship with John were clearly coloured by bouts of depression, she was profoundly influenced by her personal, therapeutic, and intellectual involvement with him. Evidence of his influence is seen in the volumes of correspondence flowing between them beginning in 1971 and continuing until John's death in 1990. During that time, Emmy wrote more than 100-some very lengthy-letters to John. Much of her correspondence was devoted to discussions about their often ambiguous and conflicted therapeutic relationship. Through an analysis of attachment theory and the nature of the client-therapist alliance, this paper offers insights into the effects that imbalances in power, expectations, and shifting needs can play in the recovery process.     

Liver failure, life support, family support, and palliation: an inside story

My sister was admitted to the intensive-care-unit (ICU) five months before she died. At the time of admission her life-support wishes were not discussed with her. During her time in the ICU, we, the family, were given hope that she may survive. As with most families, we wanted my sister to live. During her progression from ICU to step-down unit to ward unit, the plan of care was not discussed, and goals were not set. Many medical teams were involved in my sister's care, and many looked at individual body parts instead of the whole person. I am a Registered Nurse at the same hospital where my sister was being cared for. Through many family meetings I was regarded as a medical professional, not as a sister. Knowing the medical system yet going through this as a family member has given me the opportunity to gain insight into what should have happened. If code status had been discussed we would have known my sisters wishes. If relevant literature pertaining to her disease and her slim chance of recovery had been brought to our attention, my sister could have died at home as she wished, and perhaps could have lived her final days in comfort.