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When disturbed from his nap in a thicket or cave near the road purchase 100 mg zudena with visa, this apparently benign sprite is alleged to have let out a yell so intense and terrifying that a passerby would be frightened to death zudena 100mg line. A panic attack is an unpredict- able acute anxiety reaction with no known significant stressor or trigger cheap zudena 100 mg with amex. The attack is frequently described by the person as involving somatic symptoms that resemble those of a heart attack. For this reason, many patients seek help at hospital emergency rooms and may develop secondary illness anxiety disorder (hypochondriasis). The attack typ- ically lasts for 5–20 minutes and is almost always characterized by both somatic and psychic symptoms (e. Usually they are fol- lowed by anticipatory anxiety (fear of having another panic attack) and active avoid- ance of certain situations in which it would be difficult or embarrassing to seek help if a panic attack were to occur. The age at onset is usually early adulthood (20–24 years), with a lifetime prevalence twice as high in women. Agoraphobia and panic disorder are frequently complicated by depressive symptoms secondary to the primary anxiety disorder, and by substance misuse for self-medication (e. It is plausible that a panic attack in the background of phobic symptom onset reflects a traumatic factor in phobias. Rather, they appear to constitute the “generalization” of an anxiety state experienced by sufferers as both psychic and somatic (e. I began to feel dizzy, like I was going to pass out—and I started to breathe fast and feel nauseated. He still did not feel quite right, describing an ongoing discomfort in social situations, wherein he would feel lightheaded and dizzy in conversation. He speculated about having an “anxiety condition,” and mentioned a “phobia for public speaking. These repetitive behaviors may become more and more inflexible; the subject may not only be forced to perform some action or mental activity, but to do so in a certain rigidly organized sequence (compul- sive rituals). The subjective experience of obsessive–compulsive problems and related symptoms and disorders is the result of many factors, including age at onset and level of insight. Although more serious obsessions, compulsions, and rituals are rare, they may persistent for years and extend to other contexts (e. From a psychodynamic perspective, obsessive–compulsive symptom formation results from unconscious conflicts, usually between drive and conscience, desire and repulsion, appetite and prohibition, or initiative and guilt. They cause much distress, inclining the sufferer to translate them into some compromise symptom or behavior (e. Symptoms may be recognized as a serious problem by the patient, and may be completely ego-dystonic, leading to an active struggle against them. Yet obsessions and compulsions may be experienced as mostly or completely ego-syntonic, and involve passive acceptance of what is considered one’s ordinary mental functioning. The two conditions, though sharing to some extent the same diagnostic “label,” are significantly different. Rather, they have personality traits, attitudes, and general behavior characterized by perfectionism, moral inflexibility, and difficulties in delegating tasks to others. Probably more than any other class of symptoms, obsessions and compulsions are present in various diagnostic categories and should be considered to a certain extent as transdiagnostic. They may affect persons with a high level of relational and social functioning, as well as patients with a frankly psychotic structure and functioning. Conveying the message that hostile and selfish thoughts are understandable and not inherently dangerous may also be of help. Although nota- bly challenging clinically, some obsessions and compulsions remit when the afflicted person can express the feelings connected with difficult experiences—especially nor- mal disappointment, anger, and grief. As noted above, obses- sions include ruminations and horrific temptations; compulsions include rituals. The subject unsuccessfully resists either one, resulting in unpleasant repetition. Onset is generally in adolescence or early adulthood and tends to be earlier in males and in those with a tic disorder. Depression is not uncom- mon, with suicidal ideation and plans related to the sense of being unable to deal with symptoms in everyday life. When insight is largely absent and close to delusional think- ing, a person is likely to project aggression into others, thereby feeling actively isolated by others or in danger from them. When individuals with this disorder are prevented from carrying out their compulsions or rituals, they may become diffusely terrified, irritable, or overtly aggressive. Behind such symptoms, psychoanalytic clinical expe- rience points to a range of unconscious concerns, including potential loss of control (especially with respect to contamination, aggression, and shame). Cognitive Patterns Insight is a critical dimension in assessing individuals with obsessions and compul- sions. Obsessions may be recognized as a mental dysfunction, something that interferes with the common functioning and flow of thinking, and may be experienced as highly ego-dystonic, disturbing, and intrusive. Magical thinking in the absence of insight may seem delusional; patients with intact insight tend to find it absurd and shameful. Compulsive activity is often a remnant of the magical thinking of early childhood, when impulses and actions were incompletely differentiated. Thus, individuals with obsessive–compulsive symptoms may be understood as having convicted themselves unconsciously of thought crimes (hostile, selfish cognitions), which continue to haunt them in the form of obsessive images and ideas, motivating attempts to expiate their guilt through rituals that repre- sent the defenses of reaction formation and undoing. In subjects with contamination obsessions and severe cleaning/washing compulsions, it is quite frequent to see health problems (e. In addition, even though it is not exactly a somatic state but rather a motor disturbance, it should be noted that patients with obsessions and compulsions may present with co-occurring motor tics (approximately 30% over a lifetime, according to recent epidemiology studies). Relationship Patterns Obsessions and compulsions may severely affect quality of life by impairing social and relational functioning. In some severe cases, they intrude into the persons’ lives, lead- ing to social isolation. In general, afflicted individuals tend to remain in relationships if they can control the partner. They may also choose significant others who actively reas- sure them in their symptoms or even become participants in their compulsive rituals. The Subjective Experience of the Therapist The internal experience of a person with an obsession has often been intuited as shaped by a struggle between besieging and besieged parts of the mind. Countertransference may be dominated by themes of “control” as patients try to control their lives and behaviors— efforts often deemed as tragically defeated. Whatever strength is expended in efforts to control inner life by throwing rejected thoughts out the window is sabotaged by their quickly and triumphantly reentering via the front door as uncontrolled compulsions. Clinical Illustration A 33-year-old man comes to a therapist after being fired for delays in completing work assignments. He is very anxious about his future, with pessimism not only about finding another job, but also about the future of his marital relationship: His wife is becoming less and less tolerant of what she calls his “manias. There are too many contaminants outside, and so I take particular care of my hands and clothes. I wash my hands up to 30 times a day, and clean my desk and computer quite often with special products to remove the dust and to kill all the germs.

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The advantage of an interview guide is that the interviewer has carefully decided how to use the limited time available in an interview situation discount zudena 100 mg line. The guide helps to make interviewing a number of different people systematic and comprehensive discount zudena 100mg, by denoting in advance the issues to be explored 100 mg zudena visa. Interview guides can be developed in more or less detail, depending on the extent to which the interviewer is able to specify important issues in advance and the extent to which it is important to ask questions in the same order to all respondents. The Standardized open-ended interview: It consists of a set of questions carefully worded and arranged with the intention of taking each respondent through the same sequence and asking each respondent the same questions with essentially the same words. The standardized open-ended interview is used when it is important to minimize variation in the questions posed to interviewees. In a fully structured interview instrument, the question would be completely specified, as would be the probes (designed to get deeper information) as well as the transition questions (designed to introduce the next topic). In multi-center studies, structured interviews provide comparability across sites. Structured 186 Research Methodology for Health Professionals questions may also compensate for variability in researcher skills. Training in the interview approach will minimize variability due to differences in experience and skill. Structured open-ended interviews may also be used to collect data before, during and after a program of intervention. A combined strategy offers the interviewer flexibility in probing and determining the appropriateness to explore certain subjects in greater depth, or even to pose questions about new areas of inquiry that were not originally anticipated in the interview instrument’s development. A common combination strategy involves using standardized interview formats at the beginning of the interview and then leaving the interviewer free to pursue any subjects of interest during the latter parts of the interview. Another combination would include using the informal conversational interview early in an evaluation report, followed midway through by an interview guide, and then closing with a standardized open-ended interview to get systematic information from a sample of participants when concluding the study. Types of questions Six kinds of questions can be asked of people depending on the topics/ subject. Different types of questions force the interviewer to be clear about what is being asked and helps the interviewee respond appropriately. These questions help to understand people’s goals, intentions, desires, and expectations, e. It is critical that the interviewer understands the difference between the two in order to know that they have the kind of answer they want for the question they are asking. The confusion sometimes occurs because the interviewer gives the wrong cues and does not ask the question correctly. When asking feeling questions, the interviewer has to ask and listen for feeling level responses. Knowledge questions: The knowledge questions inquire about the respondent’s factual knowledge. Sensory questions: The sensory questions ask about what is seen, heard, touched, tasted, and smelled. Sensory questions attempt to have the interviewees describe the stimuli they experience. Answers to these questions help the interviewer locate the respondent in relation to other people. Qualitative inquiry is particularly appropriate in finding out how people perceive and talk about their background. Sequencing of questions: Always begin an interview with non- controversial present behaviors, activities and experiences. Then opinions and feelings may be solicited, building on and probing for interpretations of the experience. Opinions and feelings are likely to be more grounded and meaningful once an experience has been relived. Background and demographic questions, depending on how personal they are, may make the respondent feel uncomfortable. If asked at the beginning of the interview they may condition the respondent to give short answers. A genuinely open- ended question minimizes the possibility of imposing predetermined responses, e. Singular questions ensure that not more than one idea is contained in any given question. The clarity of questions is enhanced by asking simple, understandable, unambiguous questions, using language and terminology that is familiar to the respondent. They imply causal relationships, which may be complex to unravel and may make respondents feel defensive. The final or closing question: It provides the interviewee with the opportunity to have the final say, e. Unlike an interview, this approach is an attempt to quantify a variable of interest by asking the participant to rate his or her response to a summary statement on a numerical continuum. If a researcher was interested in measuring attitudes toward a class in research methods, he or she could develop a set of summary statements and then ask the participants to rate their attitudes along a bipolar continuum. One statement might look like this: on a scale of 1 to 5, please rate the extent to which you enjoy the fried foods. The use of global ratings is also common when asking participants to rate emotional states, symptoms, and levels of distress. The strength of global ratings is that they can be adapted for a wide variety of topics and questions. Despite this, researchers should be aware that such a rating is only a global measure of a construct and might not reveal its complexity or more subtle nuances. Focus group Discussion (FgD) Details are given in the chapter on qualitative research methods: Focus group is a complementary technique to individual interviews. It is a discussion on a specific topic, with a small group of people (6–10) with similar backgrounds who participate in the discussion for 1–2 hours. The objective is to get high quality data in a social context where people can consider their own views in the context of the views of others. Data Collection Methods and Techniques 189 Two people need to conduct the focus group discussion–one who concentrates on moderating/facilitating the discussion, and the other who concentrates on taking detailed notes, and who also deals with mechanics, e. The advantages of focus group discussions: • Cost effective: In an hour, one can gather information from eight people as opposed to just one person. Participants tend to provide checks and balance for each other which reject false or extreme views. The limitations of focus group discussions are: • The number of questions that can be asked is greatly restricted in the group setting. A rule of thumb: “With eight people and one hour for the focus group discussion aim to ask no more than 10 major questions”. The moderator must manage the discussion so that one or two people do not dominate it, and enable those that are less verbal to share their views.

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Let’s look at the decision-making process so we can see where the components of evidence based practice ft in discount zudena 100mg with amex. Hastie and Dawes (2010) state that decision making is made up of three parts: • There has to be more than once course of action order 100 mg zudena overnight delivery. Recognizing that there is more than one possible course of action is part of making a professional judgement order zudena 100 mg amex. Evidence is then used to consider the expected outcomes of the decision and the possible consequences. Standing (2005: 34 and 2010) has defned decision making as: A complex process involving information processing, critical thinking, evaluating evidence, applying relevant knowledge, problem solving skills, refection and clinical judgement to select the best course of action which optimises a patient/client’s health and minimises any potential harm. There are many different activities and decisions that require the use of evidence. Thompson and Stapley (2011) highlighted several decision types: • Decisions about interventions • Decisions about which patients or clients will beneft most from an inter- vention • Decisions about the best time to intervene • Decisions about when to deliver information • Decisions about how to manage a service or care delivery • Decisions about how to reassure patients and clients. We have described some of the varied decisions you may have to make and the different types of evi- dence you may draw upon in the examples below: Examples of different decisions Example: If you are a midwife, you might regularly give advice about breast feed- ing. Some mothers might be struggling to breast feed and you might be tempted to suggest supplementing with bottle feeding as you have heard others do. You need to check the evidence behind this and ensure that you give the best avail- able advice to new mothers and their babies. In this case, the evidence you need is research that addresses the best form of nutrition for new born babies. Example: If you are a social worker, you might regularly need to assess risk of depression in clients and you need to be able to suggest effective strategies to support your client. In this case, the evidence you need is research that addresses the types of interventions that are effective. Example: If you are a surgical nurse, you might regularly need to give an intra- muscular injection and you need to know the best site for the injection and the best technique to use. In this case, the evidence you need is evidence which addresses the most appropriate site for giving an injection. Example: If you are an occupational therapist, you might regularly need to dis- cuss fall prevention strategies with clients. In this case, the evidence you need is that which is concerned with effectiveness of different fall prevention strategies. Example: If you are a physiotherapist, you might regularly give advice to cli- ents with tendonitis and need to know about the effects of exercise versus rest versus alternative strategies. In this case, the evidence you need is that which has evaluated the effectiveness of various interventions for tendonitis. Example: If you are working with vulnerable people, you might regularly need to monitor the fuid intake of your clients to ensure they do not suffer from dehydration. In this case, the evidence you need is about the importance of adequate hydration. The consequences and implications of your decision Some decisions will be more important than others. This will depend on the nature of the risk or potential for harm involved to the patient/client in undertaking or omitting the intervention and the cost involved. If mothers and babies are not appro- priately supported in breast feeding, the longer term health of the baby may suffer. If the occupational therapist does not give appropriate advice regarding falls prevention, a patient or client may have a serious accident. Even if the decision does not appear life threatening – for example, the management of tendonitis – these conditions can have serious impact on the quality of the person’s life. Below, we have given an example of a decision which most people would probably consider to have few implications and an example of a decision which most people would probably consider to be more serious. Example 1: A person with high blood pressure asks you if there is any truth in the idea that eating garlic can reduce blood pressure. This is a low risk intervention – people eat garlic all the time and there are no known disadvantages in doing so. As a low risk intervention, investigation would probably not ordinarily be your priority. However the patient’s confdence in you is likely to be improved if you refer to recent evidence. Example 2: A person in a health or social care setting notices that not all staff are washing their hands between each patient or client that they look after. The decision of the healthcare provider to omit hand hygiene is a high risk omission. There is evidence that all health and social care practitio- ners should thoroughly decontaminate their hands between every episode of patient/client contact. The evidence is very strong that hand cleansing is probably the most important strategy in infection control and this has been shown in many large reviews of research studies, for example Jefferson et al. This is an inexpensive task but a highly effective one which can have serious consequences if not meticulously followed. However it is very diffcult to assess the urgency or importance of decisions we make – what is important to one person may be less important to another and so on. The greater the risk to the patient/client or likelihood of harm, the more important it is that our practice is based on evi- dence. However it is good practice to consider the evidence base behind all of the practice we undertake. Finding out that there is no available research evidence, rather than assum- ing that there is none, is very valuable information which you can use to justify why you need to use other forms of evidence. Just as there are many types of decisions that you make on a daily basis, there are also many types of evidence you will use to underpin those decisions. In general terms, you should adopt the most appropriate care and be able to justify it with reference to the most appropriate evidence. This is because research provides direct observation of the effect of interventions and care procedures on the patient/clients and clients them- selves or as in the case of qualitative research, provides us with insight so that we may more fully understand a situation or the service users’ experiences. Ideally, this research will form the basis of policy and guidelines or care path- ways. You might also draw on local policy, which has been developed for the management of complex situations. If there is no research evidence, you might draw on established scientifc information and use this evidence to make rea- soned deductions about what you need to know. Sometimes you will not look to research to make your decision but would need different evidence, for example policy documents, legal precedents, or ethical principles. Whether or not we defne policy, law and ethics as ‘evidence’ is something that could be debated. However they certainly amount to rationale from which we draw to inform our practice. Your practice would not withstand scrutiny if you relied on out-dated policy, or unlawful or unethical practice. Standing (2008) argues that there are likely to be many other factors that you consider when making a decision and it will depend on the complexity of the decision and the time available.

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