By B. Kulak. Christendom College. 2019.

Usually an active rehabilitation program is started as soon as the patient regains consciousness purchase propranolol 40 mg. The patient is first taught to maintain balance while sitting and then to learn to balance while standing order propranolol 80 mg with visa. If the patient has difficulty in achieving standing balance, a tilt table, which slowly brings the patient to an upright position, can be used. Tilt tables are especially helpful for patients who have been on bed rest for prolonged periods and have orthostatic blood pressure changes. If the patient needs a wheelchair, the folding type with hand brakes is the most practical because it allows the patient to manipulate the chair. The chair should be low enough to allow the patient to propel it with the uninvolved foot and narrow enough to permit it to be used in the home. When the patient is transferred from the wheelchair, the brakes must be applied and locked on both sides of the chair. A chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. As the patient gains strength and confidence, an adjustable cane can be used for support. Generally, a three- or four-pronged cane provides a stable support in the early phases of rehabilitation. Preventing Shoulder Pain As many as 70% of stroke patients suffer severe pain in the shoulder that prevents them from learning new skills. Shoulder function is essential in achieving balance and performing transfers and self-care activities. Three problems can occur: painful shoulder, subluxation of the shoulder, and shoulder–hand syndrome. A flaccid shoulder joint may be overstretched by the use of excessive force in turning the patient or from overstrenuous arm and shoulder movement. To prevent shoulder pain, the nurse should never lift the patient by the flaccid shoulder or pull on the 394 affected arm or shoulder. If the arm is paralyzed, subluxation (incomplete dislocation) at the shoulder can occur as a result of overstretching of the joint capsule and musculature by the force of gravity when the patient sits or stands in the early stages after a stroke. Shoulder–hand syndrome (painful shoulder and generalized swelling of the hand) can cause a frozen shoulder and ultimately atrophy of subcutaneous tissues. Many shoulder problems can be prevented by proper patient movement and positioning. The flaccid arm is positioned on a table or with pillows while the patient is seated. Some clinicians advocate the use of a properly worn sling when the patient first becomes ambulatory, to prevent the paralyzed upper extremity from dangling without support. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. The patient is instructed to flex the affected wrist at intervals and move all the joints of the affected fingers. Elevation of the arm and hand is also important in preventing dependent edema of the hand. Patients with continuing pain after attempted movement and positioning may require the addition of analgesia to their treatment program. Amitriptyline hydrochloride (Elavil) has been used, but it can cause cognitive problems, has a sedating effect, and is not effective in all patients. The antiseizure medication lamotrigine (Lamictal) has been found to be effective for poststroke pain, and it may serve as an alternative for patients who cannot tolerate amitriptyline (Nicholson, 2004). Enhancing Self-Care As soon as the patient can sit up, personal hygiene activities are encouraged. The patient is helped to set realistic goals; if feasible, a new task is added daily. Such activities as combing the hair, brushing the teeth, shaving with an electric razor, bathing, and eating can be carried out with one hand and are suitable for self-care. Although the patient may feel awkward at first, the various motor skills can be learned by repetition, and the unaffected side will become stronger with use. A small towel is easier to control while drying after bathing, and boxed paper tissues are easier to use than a roll of toilet tissue. Return of functional ability is important to the patient recovering after a stroke. The family is instructed to bring in clothing that is preferably a size larger than that normally worn.

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Chapter 4 dis- If a program cannot provide onsite ancillary cusses risk factors for suicide and recommend- services discount propranolol 80 mg with visa, it is important that staff members ed treatment responses propranolol 40 mg amex. Risk factors do not identify co-occurring disorders early so that predict individual behavior, but a high-risk they can refer patients to appropriate profile merits immediate and ongoing attention resources. In an early work, attempts or difficulty controlling violent behav- Kosten and Rounsaville (1988) found that acci- ior during their lifetimes (Cacciola et al. More recently, Darke and selves or others or have psychotic symptoms or Ross (2001) reported that 92 percent of disordered thinking that could interfere with patients who overdosed characterized the their safety or that of others should receive overdose as accidental. In that study, of the 40 immediate, aggressive intervention on admis- percent who acknowledged a previous suicide sion and throughout treatment. Staff members attempt, only 10 percent deliberately overdosed should be trained to notice indications of with heroin compared, for example, with 21 suicidal or homicidal risks. These observations percent who deliberately overdosed with should be documented and communicated to benzodiazepines. This is 202 Chapter 12 important for patients who appear withdrawn, other mood stabilizers or antidepressants take depressed, angry, or agitated or are known to hold, which can take several weeks. Medication- have experienced a recent significant loss or assisted treatment of acute suicidality should be other source of stressóespecially if a co- on an inpatient basis unless family members or occurring disorder is suspected or diagnosed or friends are willing to be responsible for adminis- if a patient still is intoxicated or withdrawing tering the drugs regularly, keeping the at-risk from a psychoactive substance. Some key factors in this decision are clearly To aid in screening and referral for suicidality expressed intent, specific and lethal plans, and homicidality, all programs should have accessible means, limited social or familial protocols in place that specify resources, severe symptoms of mental illness or psychosis, command hallucinations, hopeless- ï W ho asks what questions or uses what ness, and previous suicide or homicide attempts. Programs should encourage participation in Decisions should be made about using antipsy- mutual-help groups that focus on the needs of chotic medications, benzodiazepines, or other people with co-occurring disorders. Exhibit 12- sedatives to establish behavioral control rapid- 3 lists some of the best known of these groups, ly (Minkoff 2000). Patients can patients attend daily (at least in the early stages explore relevant themes by emphasizing positive of treatment) and onsite physicians and other coping strategies and sharing experiences. Exhibit 12-4 Topics for Psychoeducational Groups for People W ith Co-Occurring Disorders ï Causes, symptoms, and treatment for substance use and co-occurring disorders ï Medical and mental effects of co-occurring disorders ï Psychosocial effects of co-occurring disorders ï The recovery process for co-occurring disorders ï Medications to treat co-occurring disorders, their side effects, and medication management ï Coping with cravings, anger, anxiety, boredom, and depression ï Changing negative or maladaptive thinking ï Developing a sober support system ï Addressing family issues ï Learning to use leisure time constructively ï Spirituality in recovery ï Joining 12-Step and co-occurring disorder recovery mutual-help groups ï Risk factors in ongoing recovery ï Understanding and getting maximum benefits from psychotherapy and counseling Adapted from Daley 2000. The psychiatric ï All prescribed psychotropic medications medications should be, in most instances, should be to treat suspected or confirmed adjunctive to other ongoing interventions, not a co-occurring disorders, not to alleviate nor- substitute for them. From a practical viewpoint and group, but all information should be commu- assuming sufficient time to observe patients nicated both in writing and orally. Methadone withdrawal fluoxetine do not increase methadone levels symptoms may occur after discon- (ProzacÆ), significantly. Increase and/or split opioid withdrawal symptoms (Eap the methadone dosage to increase et al. Tricyclics Methadone impairs the metabolism Adjust doses of tricyclic desipramine, of tricyclics and can cause medications as needed; monitor increased tricyclic medication blood levels if clinically indicated. However, evidence sug- example is a study of patients with chronic gests major differences in the abuse liability of depression who were treated with the tricyclic benzodiazepines. Fifty-seven percent of action such as oxazepam rarely are mentioned imipramine-treated patients showed both signifi- as substances of abuse, have a wide margin of cant improvement in mood and some decreases safety, and are effective in reducing anxiety, in illicit drug use according to self-reports, com- even over extended periods (Sellers et al. Sellers and colleagues also found a to presume that tricyclic medications are ìserious pattern of nontherapeutic benzodi- unique among antidepressants improving azepine use. Mood stabilizers shown to be effective include lithium, valproate, and The consensus panel believes that patients who carbamazepine (Hellewell 2002). Lamotrigine have a history of benzodiazepine abuse should (LamictalÆ) also has been shown to be effective. Some Patients sometimes respond better to one drug drug-testing laboratories can determine specific class or a specific drug in a class. If such a another antidepressant should be considered if resource is available, testing can determine patients do not respond to their first one after a whether patients are using only their prescribed 4- to 8-week trial. Some antidepressants also benzodiazepines or supplementing them with have sedative effects (e. The latter would indi- [RemeronÆ], trazodone, and some tricyclic cate a need to change patientsí treatment plans. Nonsedating antidepressants Stimulants such as methylphenidate (RitalinÆ) might be especially useful for patients with are the treatment of choice for childhood psychomotor inhibition. However, they should be monitored carefully because some patients have abused Collaboration Betw een them by injection, and medical complications Counselors and Physicians can result from long-term injection use. Antipsychotic medication, along with physician to report side effects or lack of psychosocial intervention, is the mainstay of relief from or worsening symptoms treatment. Newer atypical antipsychotic medi- ï Supporting patients to continue taking cations for schizophrenia are preferred over medication, even when they feel better. Internet Resources for Accessing Psychiatric Instrum ents ï Comorbidity and Addictions Center: George ï National Institute on Alcohol Abuse and Warren Brown School of Social Work Alcoholism (www. Lists 175 instru- first published in Assessing Alcohol ments for measuring aspects of substance use Problems: A Guide for Clinicians and and psychopathology with hyperlinks to Researchers (Allen and Columbus 1995).

These strategies with provider views of what is in their best ìare based on the assumption that patients interests risk administrative discharge or other have the necessary skills to produce drug-free sanctions buy cheap propranolol 40 mg on line. A working familiarity with their best interests such studies provides treatment providers with a reasonable basis to choose beneficence over ï Disagreement about goals between patients autonomy when they conclude that they know and treatment providers better than patients what is in patientsí best ï Attention to community concerns interest purchase 40mg propranolol with visa. These providers might draw on agents of conventional society (Hunt and lessons from physicians caring for patients with Rosenbaum 1998). Based on the complain because they have a sense of power- disease model underlying comprehensive main- lessness and do not want to jeopardize their tenance treatment, total abstinence may be treatment. Rather than assuming that the tilt the continuing but reduced presence of symp- toward beneficence is always correct, treatment toms, they are not defining addiction as a dis- providers and administrators should ask them- ease. The long-term goal is always reducing or selves in each case whether they are striking eliminating the use of illicit opioids and other a proper balance between these two fundamen- illicit drugs and the problematic use of pre- tal principles. This dependence was particularly troubling to them because of the increasing insecurity of subsidized slots. Many users expressed concern about once having entered the system and accepting its lifestyle with little or no warning they would be ejected from it. Involuntary discharge ment, in most cases, will halt their recovery or appears to breach practitionersí duties to put precipitate relapse (Knight et al. Involuntary dations addressing involuntary withdrawal discharge of such a patient, although not in his from treatment for nonpayment of fees or her best interests, takes into account the (www. The consensus panel believes that patient behavior threatening the safety of patients and Failure to respond staff or the status of the program in the com- Another difficult ethical issue occurs when an munity is grounds for patient discharge. W hen limited slots existóbecause of However, increased take-home privileges may the limits of public sector funding or regula- pose a risk to a patient of overmedication and tory caps on slotsóand applicants are wait- lethal use and to people in the community of ing for treatment, pressure mounts to dis- drug diversion or accidental life-threatening charge patients who are not fully compliant ingestion by intolerant individuals (e. Arguably, when treatment patients or others (42 Code of Federal providers do not discharge noncompliant Regulations, Part 8 ß 12(i)(2)). Therefore, it is important treatment noncompliance based on factors to consider a patientís behavior carefullyónot and principles discussed above and patientsí just the time in treatmentóbefore allowing specific circumstances. Some States require and discussing potential conflicts with patients additional due-process procedures. The goal always is reducing or eliminating the use of illicit opioids and other illicit drugs and the problematic use Ethics: Conclusion of prescription drugs. Exhibit D- some ethical dilemmas by remaining aware of 3 provides Internet links to the ethical guide- sources of potential conflict, keeping ethical lines of other treatment-centered organizations. The patient is assured of due process if the discharge is administrative in nature. Senior Staff Associate Medical Director Behavioral Health Care W e Care Methadone Clinic National Association of Social W orkers Laurel, Maryland W ashington, D. Shirley Beckett Medical Director Certification Administrator Adult Addiction Services National Association of Alcoholism & Anne Arundel County Department Drug Abuse Counselors of Health Alexandria, Virginia Annapolis, Maryland Brent Bowman Joel A. Mobile Health Services Director Baltimore, Maryland Outpatient Services Alexandria Mental Health, Mental James F. Retardation, and Substance Abuse Executive Vice President Services American Society of Addiction Medicine Alexandria, Virginia Chevy Chase, Maryland Janice Ford Griffin Cynthia Cohen, R. Office of Substance Abuse Chief Medical Officer American Psychological Association D. Authority Anchorage, Alaska North Carolina Division of Mental Health, Developmental Disabilities, and Janet Aiyeku, M. Developmental Disabilities, and Pittsburgh, Pennsylvania Substance Abuse Services Raleigh, North Carolina G. Bureau of Substance Abuse Services and Executive Director Licensure Connecticut Counseling Centers, Inc. Decatur, Georgia Assistant Director Division of Substance Abuse and Susan Mayo Bosarge Mental Health State Methadone Authority Department of Human Services Behavioral Health Services Division Salt Lake City, Utah New Mexico Department of Health Santa Fe, New Mexico George K. Newtown, Pennsylvania Psychologist/Director of Outpatient Services Addiction Treatment Center Glen J. Veterans Affairs Puget Sound Health Care President System Pennsylvania Association of Methadone Seattle, W ashington Providers Allentown, Pennsylvania James C. Head Nurse/Unit Manager Program Director Methadone Program New Directions Treatment Services Kent County Counseling Services W est Reading, Pennsylvania Dover, Delaware Kay M. Director Administrative Director Family Centered Substance Abuse Services Adult Services Clinic Drug Abuse Comprehensive Coordinating Cornell Medical College Office, Inc. Coordinator of Addiction Medicine Nurse Coordinator New York State Office of Alcoholism and Sinai Hospital Addictions Recovery Substance Abuse Services Program Albany, New York Baltimore, Maryland Carol Davidson, M. Associate Professor of Medicine Boston, Massachusetts Johns Hopkins Bayview Medical Center Baltimore, Maryland Peter A. Tuttleman Counseling Services Medical Advisor Philadelphia, Pennsylvania Office of Research on W omenís Health National Institutes of Health John de Miranda, Ed. Bethesda, Maryland Executive Director National Association on Alcohol, Drugs and Disability San Mateo, California Field Review ers 309 Michael T.

Scores are recorded as high (above the median) or low (below the median) to reflect coping characteristics of the 98 study group (James cheap propranolol 80mg visa, 1996; James et al purchase propranolol 40mg fast delivery. However, by age 60 active coping begins to taper as employment and career goals decrease in intensity. Because this tool is important in answering the research questions, the age group of 18 to 60 was included in this study. Responses are scored on a 5-point Likert scale (0=this has never happened to me, 1=event happened but did not bother me, 2=event happened and I was slightly upset, 3=event happened and I was upset, and 4=event happened and I was extremely upset). Scores of global racism or total scale result by converting each subscale score to z scores before summing the scores of each subscale. In a study conducted by Utsey (1999), the 22-item questionnaire was tested on a sample of 239 Black male (n=78) and female (n=138) college students, substance abuse program clients, and an area community along with a subsample of Whites (n=25). Responses are scored on a 4-point Likert scale (not at all=0, several days=1, more than half the days=2, and nearly every day=3). A score of 0-4 represents no depressive symptoms, 5-9 represents minimal depressive symptoms, 10-14 represents minor depressive symptoms, 15-19 represents moderately severe depressive symptoms, and 20-27 represents severe 100 depression symptoms. Any person scoring 5 to 9 were classified as having minimal symptoms of depression, while scores of 10 to 14 were classified as possibly clinically significant, and scores of 15 to 19 and 20 to 27 were classified as warranting active treatment (Spitzer, Williams, & Kroenke, n. An additional item at the end of the tool addressed problem areas checked on the questionnaire: ―How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people‖ (Kroenke et al. Study participants in the medicine clinics had a mean age of 46 (±17), and the majority were White (79%) women (66%), while the obstetrical-gynecology participants were all women (100%) with a mean age of 31 (±11), and the majority were White (39%) and Hispanic (39%). This scale uses true-false questions whereby higher scores reveal the tendency to provide socially desirable answers. According to Crowne (1960), the initial study revealed a Kuder-Richardson formula 20 (K-R 20) reliability coefficient of 0. In a study conducted by Strahan and Gerbasi (1972) to form a new scale with fewer items, a sample of 176 non-college and college males and 185 college and university females were tested. Of the shorter scales, the M-C 1(10) was deemed slightly superior because reliability coefficients were similar across 102 diverse samples when compared to the M-C 2(10), thus, the M-C 1(10) was used for this study. Procedures All potential participants were informed of the study through one or more mechanisms that included flyers, announcements, or social nomination. All questions regarding the study were answered, and if the individual met the inclusion criteria and agreed to participate in the study, an appointment was made to conduct an interview for data collection. Reading the consent form prevented any issues of illiteracy that may affect participation and cause embarrassment (Waltz, Strickland, & Lenz, 2005). After the informed consent was obtained, each participant was assigned an identification number with a designated folder for their data tools. Height was measured using a portable Seca 217 stadiometer with measurements to the nearest 0. With a Gulick tape measure (which included a mechanism to ensure consistent tension when measuring), waist circumference was measured to the nearest 0. The participant stood in an upright position without sucking in the abdomen while the tape was pulled taut without squeezing into the skin. Waist circumference body fat of more than 35 inches (89 cm) for women and more than 40 inches (102 cm) for men increases the risk of heart disease (Heaner, n. Direct visualization of all medications allowed for accurate documentation of medication names, dosages, and time frequencies for administration. In addition, direct 105 visualization minimized embarrassment if names of medications were not known or pronounced correctly. Depression is often unrecognized and therefore not treated, especially in Black women (Artinian, Washington, Flack, Hockman, & Jen, 2006). There was a strong possibility that some study participants may not be able to read because of illiteracy or low literacy skills (Flack et al. This process helped to prevent embarrassment and ensure clarity and understanding of the questions. When instruments had Likert scale responses, the scale was provided to participants as a visual aid during the interview. Respondent fatigue was addressed by alternating the various types of scales, keeping the participant‘s interest by rotating between dull and interesting questions, and controlling the number of questions. In addition, participants were offered a break to prevent fatigue during data collection. Overall results of the research study will be shared with participants upon request while ensuring confidentiality of individual responses. Data Analyses Descriptive statistics were used to describe the demographic characteristics of the sample population. The Shapiro-Wilk test was used to assess normality of all independent variables (Norusis, 2008). In addition, all continuous data had calculated means, ranges, standard deviations, frequencies, skewness, kurtosis, and graphic plots to examine the 107 distribution and cause of nonnormal data. The Mann-Whitney U test was used for non-normally distributed continuous variables (number of medications), and cross-tabulations with Chi-Square test was used for categorical variables (education and type of health coverage). The Fisher‘s exact test was used to examine the significance of association (contingency) between background and dynamic variables on medication adherence in place of a phi correlation coefficient because data were sparse.