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Lewin’s strategy Lewin’s (1952) classic work on change management includes: ■ field theory ■ stages of change Lewin’s field theory suggests that opposing forces both drive and restrain change buy generic prednisone pills allergy symptoms hiv. Habit purchase genuine prednisone line allergy symptoms 7 months, often enshrined in rituals (Walsh & Ford 1989; Ford & Walsh 1994) is a major restraining force buy prednisone mastercard allergy shots high blood pressure. More widely cited is Lewin’s three stages of change: Intensive care nursing 452 ■ unfreezing (destabilising) ■ moving (changing) ■ refreezing (re-establishing) Unfreezing, breaking habits and rituals, creates motivation for change. Wright (1998) suggests that unfreezing may occur when: ■ expectations have not been met ■ staff have uncomfortable feelings about something ■ obstacles to change are removed (‘psychological safety’) Moving occurs when change is planned and initiated. Stability may have been possible when Lewin published his ideas in 1952, but if change and instability are now the norm (Toffler 1970), unfreezing may be unnecessary and refreezing impossible; change agents may only have to plan the moving stage. Human needs Change causes stress for everyone, including (often especially) change agents. Failed initiatives can leave change agents physically and emotionally exhausted, while ‘shifting sand’ quickly buries their ideas. Familiarity breeds contempt (the ‘wallpaper effect’ (Wright 1998): we cease to notice familiar problems); change agents may become conservative, defending their own change against any subsequent developments. However, safety needs should be balanced against the benefits of taking risks; this does not mean turning off ventilators each shift to see whether patients can breathe on their own, but it does include taking calculated risks when the likely benefits appear to outweigh the possible dangers. Nursing has inherited a culture of negative criticism, which undermines the confidence of nurses who usually only receive feedback when they have done something wrong. Pressures should be recognised, and Managing change 453 planned for; actions should be specific and timetabled, with achievable targets for everyone to work towards. It is necessary therefore to plan: who will achieve something by what date how all staff will be made aware of changes how they will be achieved, and where specific events will occur Plans which remain flexible and adaptable are more likely to succeed (Wilkinson 1994); targets may need modification later. Evaluation However good ideas may sound, their effects in practice, together with their strengths and weaknesses, should be evaluated and, if necessary, the ideas should be modified, developed further, or even abandoned. Evaluations may be achieved through questionnaires, interviews, or more informal approaches. Beyond change Having successfully seen through changes, staff should gain satisfaction (boosting morale) from positively contributing to practice. Experience may be disseminated within the hospital, and beyond—for instance, are there hospital-wide forums where you work? If not, consider the mounting of study sessions/days, or the publication of articles. Extending practice should be part of each nurse’s professional development, and so relevant material, with written reflections on the process, can provide valuable additions to professional profiles. Implications for practice ■ change will occur, and the rate of change will increase ■ nurses can either proactively manage change or reactively be managed by others Intensive care nursing 454 ■ any change forced on people against their will is usually overturned at the earliest opportunity ■ change management should therefore seek to alter values ■ bottom-up approaches are more likely to succeed, as they adopt the norms of majorities ■ change is stressful for all concerned, and so should be carefully planned ■ detailed planning, with specific target dates and achievable goals, helps to prevent procrastination ■ change agents should facilitate informed decision making ■ change agents should acknowledge their own and others’ limitations ■ all staff are likely to need support through the stressful time of change ■ opposition to change can provide a forum for constructive debate ■ change agents should pre-plan how and when their initiative will be evaluated, and be prepared to modify plans where necessary Summary The pace of change is accelerating; nurses and nursing can choose between managing change or being managed by others. Other chapters in this book may have triggered ideas that readers wish to translate into practice.

Homicides may also result in the murderer taking his or her own life following the violent act that resulted in the death of the intimate partner discount prednisone 10 mg line allergy symptoms red ears. It has been reported that 74% of all murder-suicides involved an intimate partner generic 40 mg prednisone amex allergy symptoms feel like flu. Of these reported cases order on line prednisone allergy medicine 8 month old, 96% were females killed by their intimate partner, with 75% of these cases occurring within the home. Estimates indicate that the annual medical expense associated with domestic violence is at least $3 billion to $5 billion. Also, businesses are reported to lose another $100 million in lost wages, sick leave, absenteeism, and loss of productivity. Te risk for facial injury was much higher among the domestic violence victims than was seen in other mechanisms of injury. Head injuries were also more common in women victims of intimate partner violence. One published study indicates that 85% of intimate partner violence victims were found to have injuries on more than one area of the body. Te most common sites for injury were the eye, side of the face, throat and neck, upper and lower arms, upper and lower legs, mouth, outside of the hand, back, and scalp. Of importance to dentists, 79% of the injuries were in areas clearly visible (injuries to the head and hands). Abuse knows no age group limitations and is seen in persons of all ages from the very young through the very old (Figures 15. Like other forms of abuse, physical abuse of an elderly individual can appear in many diferent patterns. Other signs are traumatic hair and tooth loss, rope or strap marks indicating physical restraint, multicolored bruises indicating injuries at various stages of healing, and injuries suggesting heal- ing “by secondary intention” (possibly indicating inappropriate or delayed presentation for care). Te National Committee for the Prevention of Elder Abuse also reports that some of the indicators of elder abuse can include: • Injuries that are unexplained or are implausible • Family members providing diferent explanations of how injuries were sustained • A history of similar injuries or numerous hospitalizations, or both • Victims brought to diferent medical facilities for treatment to pre- vent medical practitioners from observing a pattern of abuse • Delay between onset of injury and seeking medical care Many of these indicators are very similar to those signs and symptoms of abuse/neglect seen in younger populations. Zeitler reported that approximately 30% of known elder abuse cases presented with neck and facial injuries. Many of the inju- ries associated with inficted trauma are seen in the maxillofacial complex. Because of the injury locations, oral health care providers may be the frst to have the opportunity to diagnose and treat the victims of nonaccidental (inficted) trauma. Plans should be in place in each oral health care facility whereby intervention can appropri- ately begin on behalf of the suspected victim of violent behavior. Without intervention, the assaults may increase, leading to serious sequelae, including death by homicide. Preventing intimate partner violence, sexual violence and child maltreatment, 1–7.

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The symptoms usually diminish during adolescence and adulthood and cheap prednisone 5 mg on-line allergy forecast burlington vt, in some cases purchase prednisone overnight delivery allergy treatment emergency, disappear altogether by early adulthood buy prednisone 20mg fast delivery allergy forecast nyc mold. Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence ● 43 Predisposing Factors 1. Family studies have shown that Tourette’s dis- order is more common in relatives of individuals with the disorder than in the general population. It may be transmitted in an autosomal pattern intermediate between dominant and recessive (Sadock & Sadock, 2007). Altered levels of neurotransmitters and dysfunction in the area of the basal ganglia have been implicated in the etiology of Tourette’s disorder. The genetic predisposition to Tourette’s disorder may be reinforced by certain factors in the environ- ment, such as complications of pregnancy (e. The disorder may begin with a single motor tic, such as eye blinking, neck jerking, shoulder shrugging, facial grimacing, or coughing. Complex motor tics may follow and include touching, squat- ting, hopping, skipping, deep knee bends, retracing steps, and twirling when walking. Vocal tics include various words or sounds such as clicks, grunts, yelps, barks, sniffs, snorts, coughs; in about 10% of cases, a complex vocal tic involves uttering obscenities. Vocal tics may include repeating certain words or phrases out of context, repeating one’s own sounds or words (palilalia), or repeating what others say (echolalia). The movements and vocalizations are experienced as compul- sive and irresistible, but they can be suppressed for varying lengths of time. Tics are exacerbated by stress and attenuated during periods in which the individual becomes totally absorbed by an activity. Client will seek out staff or support person at any time if thoughts of harming self or others should occur. Recog- nition of behaviors that precede the onset of aggression may provide the opportunity to intervene before violence occurs. Provide hand coverings and other restraints that prevent client from self-mutilative behaviors. Excess energy is released through physical activities and a feeling of relaxation is induced. Children on this medica- tion must be monitored for adverse effects associated with most antipsychotic medications (see Chapter 28). Because of the potential for adverse effects, haloperidol should be reserved for children with severe symptoms or with symptoms that interfere with their ability to function. The response rate and side effect pro- file of pimozide are similar to those of haloperidol. It is used in the management of severe motor or vocal tics that have failed to respond to more conventional treatment.


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It is the second most widely used compound and is employed as a diluent cheapest generic prednisone uk allergy medicine red eyes, filler or binder in tablets order cheap prednisone allergy medicine kidney disease, capsules and other oral product forms cheap 20 mg prednisone allergy jewelry. As lactose is only 30 per cent as sweet as sugar it is used as a sugar supplement, and also in food and confectionery. Sucrose Sucrose is a disaccharide that is composed of a unit of glucose (acetal form) and a unit of fructose (ketal form) linked through C-1 of glucose and C-2 of 0 fructose, i. In sucrose, neither glucose nor fructose can exist in open chain form because of the formation of acetal and ketal as shown below. This phenomenon of sucrose is called the inversion of sucrose, and the resulting mixture is known as invert sugar, which is the main component of honey, and is sweeter than sucrose itself. Starch and cellulose are the two most important polysaccharides from biological as well as economical viewpoints. Starch Starch, an essential component of our diet, is a high molecular weight polymer of glucose where the monosaccharide (glucose) units are linked mainly by 1,4 -0 a-glycoside bonds, similar to maltose. Starch is obtained from wheat (Triticum sativum), rice (Oryza sativa)andmaize(Zea mays), all from the plant family Gramineae. Potato (Solanum tuberosum; family Solanaceae) and maranta (Maranta arundinacea; family Marantaceae) are also good sources of starch. Starch consists of two main components: amylose (insoluble in cold water) and amylopectin (soluble in cold water). Amylose, which accounts for about 20 per cent by weight of starch, has an average molecular weight 6 of over 10. It is a polymer of glucopyranose units linked together through a 1,4 -linkages0 in a linear chain. This is the colour reaction of iodine in starch, a confirmatory test for the presence of starch. Amylopectin contains branches (nonlinear), approximately one in every 20 to 25 glucose units. Starch soaks up secretions and helps to render injured parts less liable to bacterial infections. As a dusting powder for application to chafings and excoriations, it is used either alone or mixed with zinc oxide, boric acid and other similar substances. Like amylopectin, 0 0 glycogen contains a complex branching structure with both 1,4 and 1,6 links, but it is larger than amylopectin (up to 100 000 glucose units) and much more branched. It has one end glucose unit (where glucose can be added or released) for every 12 units and a branch in every six glucose units. Cellulose Cellulose, the most abundant natural organic polymer, consists of several thousands of D-glucose units linked by 1,4 -0 b-glycoside bonds as in cellobiose. Different cellulose molecules can then interact to form a large aggregate structure held together by hydrogen bonds.