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Rather than face rejection and ridicule buy silagra 50mg cheap, he locks himself away in solitary confinement silagra 100 mg mastercard. His com- bination of fear and yearning motivates him to see a therapist, and he manages to tell his therapist about his lifelong secret. Jeremy’s therapist suggests that he start examining his thoughts with a Thought Tracker (see Worksheet 6-1) and then take his thoughts to Thought Court. Worksheet 6-1 Jeremy’s Thought Tracker Feelings & Sensations Corresponding Events Thoughts/Interpretations (Rated 1–100) Anxiety (85), fear Chelsea asks me out for I can’t possibly go out with her. Anxiety (75), The guys asked me to go The shame would overwhelm shame (85), bitter into the hot tub with them me. Chapter 6: Indicting and Rehabilitating Thoughts 79 Jeremy’s most malicious thoughts: 1. Next, his therapist suggests that Jeremy put the first of these thoughts on trial using a worksheet (later on, they address his other malicious thought). As you can see in Worksheet 6-2, Jeremy writes down the malicious thought first and then in one column defends the thought by listing all the reasons, logic, and evidence he can muster to support the case that the thought is true. In the other column, Jeremy attempts to prosecute the thought by demonstrating that it’s false. Worksheet 6-2 Jeremy’s Thought on Trial Worksheet Accused thought: I couldn’t stand to see the look of repulsion on her face. I’ve seen the look of shock on people’s My family seems to have gotten faces before. After one surgery, a physical therapist made a comment that my burns were permanently deforming and I’d just have to learn to live with them. So far, this case is going very well for the defense and very poorly for the prosecution. Thus, Jeremy remains quite convinced that his thought is a true reflection of reality; it’s just the way things are. The therapist tells him he’s made a good start but asks him to consider the Prosecutor’s Investigative Questions in Worksheet 6-3 and write down his reflections on those questions (see Worksheet 6-4). Do I know of friends or acquaintances who have experienced similar events but for whom this thought wouldn’t apply? Worksheet 6-4 Jeremy’s Reflections These questions are a little difficult to contemplate. Well, I guess I would really dislike seeing repulsion on her face, but I could probably “stand it. And I suppose I’ve seen attractive women who are with guys who have substantial disabilities like morbid obesity, missing limbs, and so on. I was in that burn support group, and I admit there were some people who had nice relationships after they’d been burned. And I guess the thought is doing me more harm than good because it keeps me from ever considering a relationship. After Jeremy reflects on the list of Prosecutor Investigative Questions, his therapist advises him to take another look at his Thoughts on Trial Worksheet and try to add more evidence and logic to his case (see Worksheet 6-5). Worksheet 6-5 Jeremy’s Revised Thought on Trial Worksheet Accused thought: I couldn’t stand to see the look of repulsion on her face. Actually, there are a few people I know who haven’t been shocked or repulsed by my scars. I’ve seen the look of shock on people’s My family seems to have gotten faces before. If they can, it’s certainly possible that others could do the same — especially if they cared about me. I can remember my mother crying when Just because my mother cried she saw how badly I was burned. Chapter 6: Indicting and Rehabilitating Thoughts 81 Defending the Thought Prosecuting the Thought After one surgery, a physical therapist The physical therapist was right in made a comment that my burns were that I do have to live with this. But permanently deforming and I’d just have that doesn’t mean I can’t have a to learn to live with them. Sometimes when I go for a checkup, I My burns are noticeable; it doesn’t hear people talking about me. If someone really likes and cares about me, she ought to be able to look past my scars. At this point, Jeremy carefully reviews the case presented in his Revised Thought on Trial Worksheet. He and his therapist agree to work on a replacement thought for his most malicious thought (see the sec- tion “After the Verdict: Replacing and Rehabilitating Your Thoughts” later in this chapter). After he creates the first replacement though, he continues putting his other malicious thoughts on trial and replacing them, one at a time. Putting your thoughts on trial You guessed it; it’s your turn to visit Thought Court.

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A modest increase in dose of such a drug disproportionately phenytoin concentration is 25μmol/L silagra 100mg fast delivery. This is very week later he is complaining of unsteadiness purchase 100mg silagra overnight delivery, there is nys- important clinically when using plasma concentrations of, tagmus and the serum concentration is 125μmol/L. Comment Key points Phenytoin shows dose-dependent kinetics; the serum con- centration at the lower dose was below the therapeutic • Two-compartment model. Despite the apparently plasma concentration falls bi-exponentially, instead modest increase (to 150% of the original dose), the plasma of a single exponential as in the one-compartment concentration rose disproportionately, causing symptoms model. In: Clinical pharmacoki- Consequently, increasing the dose causes a netics: concepts and applications, 3rd edn. These are permeable to lipid-soluble drugs, whilst pre- senting a barrier to more water-soluble drugs. The most convenient route of drug administration is usually by mouth, and absorption processes in the gastro-intestinal tract are among the best understood. Unless administered intravenously, most drugs are in gut wall absorbed incompletely (Figure 4. However, differences in bioavailability did account for an epi- Bioavailability of a drug formulation can be measured experi- demic of phenytoin intoxication in Australia in 1968–69. Restoring the original manufactur- ing conditions restored potency but led to some confusion, with Many factors in the manufacture of the drug formulation influ- both toxicity and underdosing. Pharmaceutical factors are therefore important should be by generic name or by proprietary (brand) name. This is determined by the lipid solubility of Time→ the drug and the area of membrane available for Figure 4. Sometimes polar drugs can be absorbed via specific transport processes (carriers). It is usually available only from the company liver, which can extract drug from the portal blood that introduced it until the patent expires. After this, other com- before it reaches the systemic circulation via the hepatic vein. This is called presystemic (or ‘first-pass’) panies can manufacture and market the product, sometimes metabolism. At this time, pharmacists usually shop • ‘Bioavailability’ describes the completeness of around for the best buy. If a hospital doctor prescribes by propri- absorption into the systemic circulation. The amount of etary name, the same drug produced by another company may drug absorbed is determined by measuring the plasma be substituted. The for- bioavailability implies that no drug enters the systemic mulation of a drug (i. This is a particular concern with slow-release or drugs and different pharmaceutical formulations of the sustained-release preparations, or preparations to be adminis- same drug, but also from one individual to another, tered by different routes. Drug regulatory bodies have strict cri- depending on factors such as dose, whether the dose teria to assess whether such products can be licensed without is taken on an empty stomach, and the presence of gastro-intestinal disease, or other drugs. The rate at which a drug enters the body determines for another may give rise to clinical problems unless the the onset of its pharmacological action, and also influences the preparations are ‘bioequivalent’. Regulatory authorities intensity and sometimes the duration of its action, and is therefore require evidence of bioequivalence before important in addition to the completeness of absorption. They provide an approach to improving (brand named or generic) are sufficiently similar for their sub- absorption and distribution. If evidence is presented that a new One approach to improving absorption or distribution to a rel- generic product can be treated as therapeutically equivalent to atively inaccessible tissue (e. This does not imply that all possible pharmacokinetic absorbed and from which active drug is liberated after absorp- parameters are identical between the two products, but that tion. There are two main mechanisms of Oral drug administration may be used to produce local effects drug absorption by the gut (Figure 4. Non-polar lipid-soluble dependent acrylic coat that degrades at alkaline pH as in the agents are well absorbed from the gut, mainly from the small intestine, because of the enormous absorptive surface area provided by villi and microvilli. Naturally occurring polar substances, including sugars, amino acids and vitamins, are Relatively well- Relatively poorly absorbed and/or absorbed and/or absorbed by active or facilitated transport mechanisms. Drugs good tissue poor tissue that are analogues of such molecules compete with them for penetration penetration transport via the carrier. The following advantages have been claimed for the rec- tal route of administration of systemically active drugs: Prolonged action and sustained-release preparations 1. Exposure to the acidity of the gastric juice and to digestive Some drugs with short elimination half-lives need to be adminis- enzymes is avoided. The portal circulation is partly bypassed, reducing ence to the prescribed regimen difficult for the patient.

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That is buy silagra 100 mg with visa, a way to illuminate the values and mean- Josephine Paterson and Loretta Zderad met in ings central to nursing experiences cheap 50 mg silagra overnight delivery. Zderad were nursing visionaries who emphasized Their joint project was to create a new program synthesis and wholeness rather than reduction and that would encompass the community health com- logical/mathematical analysis. They challenged the ponent and the psychiatric component of the notion that the reductionistic approach is the graduate program. This started a collaboration, di- touchstone of explanatory power, and they postu- alogue, and friendship that has lasted for over 45 lated an “all-at-once” character of existence in years. They shared and developed their concepts, nurses’ experiences of being in the world. They led approaches, and experiences of “existential phe- the way to many of the contemporary nursing the- nomenology,”which evolved into the formal Theory ories that emphasize the caring aspects of nursing of Humanistic Nursing. It speaks to the essences of nursing and embraces They were hired as “nursologists” by a forward- the dynamics of being, becoming, and change. It is also a theory that provides a three-pronged approach to the improvement of pa- methodological bridge between theory and practice tient care through clinical practice, education, and by providing a broad guide for nursing “dialogue” research. Nursing, as seen through Humanistic Nursing They worked with the nurses at Northport from Theory, is the ability to struggle with another 1971 until 1978 on this project, running workshops through “peak experiences related to health and suf- that incorporated their theory. In 1978 there was a fering in which the participants are and become in change in hospital administration that entailed a accordance with their human potential” (Paterson reorganization of services. According to Josephine Paterson and community, or from humanity for help Loretta Zderad, in nursing, the purpose of this dia- with some health-related issue. A nurse, a logue, or intersubjective relating, is, “nurturing the group of nurses, or the community of well-being and more-being of persons in need” nurses hearing and recognizing that call respond in a manner that is intended to In nursing, the purpose of this dialogue, or help the caller with the health-related intersubjective relating, is,“nurturing the need. What happens during this dialogue, well-being and more-being of persons in the “and” in the “call and response,” the need. Humanistic Nursing Theory is dialogue, the “and” in the “call and response,” the grounded in existentialism and emphasizes the “between,” is nursing. The method is phenomenological in- The new adventurer in Humanistic Nursing quiry (Paterson & Zderad, 1976 p. Engaging Theory may at first find some of these terms and in the phenomenological process sensitizes the in- phrases awkward. When I spoke to a colleague of quiring nurse to the excitement, anticipation, and the “moreness” and of “relating all at once,” she re- uncertainty of approaching the nursing situation marked, “Oh, oh, you’re beginning to sound just openly. Consider Josephine Paterson’s flective immersion in the lived phenomena” own description of humanistic nursing: “Our ‘here (Zderad, 1978, p. During this interchange, the nurse calls forth all If asked to conceptualize Humanistic Nursing that she is (education, skills, life experiences, intu- Theory succinctly, I would have to say, “call and ition, etc. Through this paradigm, Josephine Paterson the nurse must provide what it is that the patient is and Loretta Zderad have presented a vision of calling for. Remember the response of the nurse is nursing that is amenable to variation in practice guided by all that she is. This includes his or her settings and to the changing patterns of nursing professional role, ethics, and competencies. A nurse, a group of nurses, or the community Look at the conceptual framework of Human- of nurses hearing and recognizing that call respond istic Nursing Theory in Figure 11–1 to help explain in a manner that is intended to help the caller with and illustrate some of its basic concepts and as- the health-related need. It also Humanistic Nursing Theory, when we speak of includes past experiences with persons in the human beings, we mean patients (e. A person becomes a patient when he viduality as incarnate human beings who exist in or she sends a call for help with some health-related this particular space at this particular time, with problem. The person hearing and recognizing the circumscribed resources and in a physical body that call is a nurse. A nurse, by intentionally choosing to senses, filters, and processes our experiences to become a nurse, has made a commitment to help which we assign subjective meanings. In humanistic nursing we say to be a unique human being with his or her own that each person is perceived as existing “all at particular gestalt (see Figure 11–3). This task You can easily see that a nursing theory that is can be done with tenderness, dignity, and with based in the human context lends itself to phenom- masterful technical skills that make the procedure enological inquiry rather than reductionism, which almost unnoticeable. I once watched as a nurse po- attempts to remove subjective humanness and sitioned and suctioned a patient; as she performed strives to achieve detached objectivity. The early the task, she made sure that she also repositioned phenomenologists saw their goal as the examina- the little basket of flowers that she had placed by tion and description of all things, including the the patient’s bedside. The repositioning of the flow- human experience of those things, in the particular ers really had nothing to do with the technique of way that they reveal themselves. It showed that the nurse recognized the Phenomenology is not only a philosophy, but it patient as a unique human being, and she did is also a method—a method that can be integrated something special to make the experience less into a general approach or way of viewing the stressful and as comfortable as possible for the pa- world. Comfort in this instance refers to the idea that clined to cultivate it and make it a part of their through the relationship engendered and nurtured everyday approach to nursing.

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Reproduced from G Thomas buy silagra 50mg otc, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science order silagra 50 mg mastercard, 1996, by permission of Prentice Hall, a Pearson Education Company and biological activity. For example, the water solubility of a protein is usually at a minimum at its isoelectric point whilst the charge on a protein may affect the ease of transport of a protein through a plasma membrane (see Appendix 5). It is also important in electrophoretic and chromatographic methods of protein analysis. Reproduced from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, by permission of Prentice Hall, a Pearson Education Company Table 1. Monosaccharides are either polyhydroxyaldehydes (aldoses) or polyhydroxyketones (ketoses), which are not converted to any simpler polyhydroxyaldehydes and polyhydroxyketones res- pectively under aqueous hydrolysis conditions. How- ever, not all polyhydroxyaldehydes and ketones are classified as carbohydrates. For example, an aldohexose is a monosaccharide that con- tains a total of six carbon atoms including that of the aldehyde in its structure. Similarly, a ketopentose has five carbons in its structure including the one in the keto group. Oligosaccharides are carbohydrates that yield from two to about nine monosaccharide molecules when one molecule of the oligosaccharide is hydrolysed. Small oligosaccharides are often classified according to the number of monosaccharide residues contained in their structures. For example, disac- charides and trisaccharides contain two and three monosaccharide residues respectively whilst polysaccharides yield larger numbers of monosaccharide molecules per polysaccharide molecule on hydrolysis. They exhibit a wide variety of biological functions but in particular act as major energy sources for the body. Those with five or more carbon atoms usually assume either a five (furanose) or six (pyranose) membered ring structure. These cyclic structures are formed by an internal nucleophilic addition between a suitably positioned hydroxy group in the molecule and the carbonyl group (Figure 1. This internal nucleophilic addition introduces a new chiral centre into the molecule. The carbon of the new centre is known as the anomeric carbon and the two new stereoisomers formed are referred to as anomers. In this convention solid lines represent bonds above the plane of the ring whilst dotted lines are used to indicate bonds below the plane of the ring. Reproduced from G Thomas, Chemistry for Pharmacy and the Life Sciences including Pharmacology and Biomedical Science, 1996, by permis- sion of Prentice Hall, a Pearson Education Company In many cases pure a- and b-anomers may be obtained by using appropriate isolation techniques. For example, crystallization of D-glucose from ethanol yields a-D-glucose [a] þ112. However, in aqueous solution these cyclic structures can form equilibrium mixtures with the corresponding straight chain form (Figure 1. The change in optical rotation due to the conversion of either the pure a- or pure b-anomer of a monosaccharide into an equilibrium mixture of both forms in aqueous solution is known as mutarotation (Figure 1. The specific rotation of the aqueous equilib- rium mixture is þ52 All monosaccharides have a number of stereogenic centres. The configurations of these centres may be indicated by the use of the R/S nomenclature system. However, the historic system where the configurations of all the chiral centres are indicated by the stem name of the monosaccharide (Figure 1. In the D form this hydroxy group projects on the right of the carbon chain towards the observer whilst in the L form it projects on the left of the carbon chain towards the observer when the molecule is viewed with the unsaturated group at the top. These configurations are usually represented, on paper, by modified Fischer projections (Figure 1. The D and L forms of a monosaccharide have mirror image structures, that is, are enantiomers (Figure 1. The system is based on the relative positions of adjacent hydroxy groups with the carbonyl group being used as a reference point for the hydroxy groups. Epimers are compounds that have identical configurations except for one carbon atom. For example, both a-D-glucose and a-D-fructose react with phenylhydrazine to form the same osazone. This means that after a short time a basic aqueous solution of a monosaccharide will also contain a mixture of monosaccharides that will exhibit their character- istic chemical properties. For example, a solution of fructose will produce a silver mirror when treated with an ammoniacal solution of silver nitrate (Tol- len’s reagent). This is because under basic conditions fructose undergoes tauto- merism to glucose, whose structure contains an aldehyde group, which reduces Tollen’s reagent to metallic silver. The approximate concen- trations of the isomers present at equilibrium are given in the brackets 1.

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