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By F. Gelford. California University of Pennsylvania.

Milieu therapies (or environmental ther- apy) focus on putting the patient in a controlled thera- peutic social setting that provides the patient with oppor- tunities to gain self-confidence and interact with peers in a positive way buy top avana 80 mg amex. Activities that encourage self-discovery and empowerment such as art, music, dance, and writing are important components of this approach. Educator and therapist Margaret Naumburg was a follower of both Freud and Jung, and incorporated art into psychotherapy as a means for her patients to visual- ize and recognize the unconscious. She published exten- sively on the subject and taught seminars on the tech- nique at New York University in the 1950s. In the 1930s, Karl, William, and Charles Menninger introduced an art therapy program at their Kansas-based psychiatric hospital, the Menninger Clinic. The Men- ninger Clinic employed a number of artists in residence in the following years, and the facility was also consid- ered a leader in the art therapy movement through the Art therapist with students. This therapy can promote physiological healing when patients identify and Art therapy provides the client-artist with critical in- work through anger, resentment, and other emotional sight into emotions, thoughts, and feelings. It is often prescribed to accompany pain control of the art therapy process include: therapy for chronically and terminally ill patients. The creation of a tangible reward Art therapy, sometimes called expressive art or art can build confidence and nurture feelings of self-worth. It is a two part process, involving both the cre- the analytical components of the artistic process. Patients are encouraged to visualize, and then create, the • Relaxation and stress relief. Stress can weaken and resulting artwork is then reviewed and its meaning inter- damage the immune system, can cause insomnia and preted by the patient. When The “analysis” of the artwork produced in art thera- used alone or in combination with other relaxation py typically allows patients to gain some level of insight GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 131 into their feelings and lets them to work through these is- string, adhesives, clay, wood, glazes, wire, bendable metals, sues in a constructive manner. Providing artists practiced in conjunction with individual, group, or fami- with a variety of materials in assorted colors and textures ly psychotherapy (talk therapy). While a therapist may can enhance their interest in the process and may result in a provide critical guidance for these activities, a key fea- richer, more diverse exploration of their emotions in the re- ture of effective art therapy is that the patient/artist, not sulting artwork. Such appropriate tools as scissors, brushes, the therapist, directs the interpretation of the artwork.

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Under- standing the approach to the evaluation of the cardiovascular system is essential to treating any critically ill patient cheap 80mg top avana with amex. Inspection Inspection of the cardiovascular system is divided into three main areas: 20 Jugular Venous Distention • Daily examination of the patient in the ICU should include examination of neck veins to look for JVD. A patient sitting at a 45-degree angle who has distended neck veins has a CVP of 12–15 cm H2O or higher. Such an injury pattern should alert the physician to the possibility of a myocardial contusion. Treatment of this condition consists of continuous ECG monitoring and vigorous correction of arrhythmias. Extremity Perfusion • Check all four extremities for distal perfusion, including pulses, color, temperature, and capillary refill. In a young, previously healthy individual, an adequate BP usually corresponds to a MAP of greater than 70 mm Hg. Technical Tip: If the cuff is too small an obese arm will give a systolic BP 10–15 mm Hg higher than the actual pressure. Systolic Hypertension: A systolic blood pressure >140 mm Hg with a normal diastolic pressure. In the acute care setting, systolic hypertension is thought to be secondary to in- creased cardiac output. Systolic hypertension is seen in the following situations: • Generalized response to stress • Pain • Thyrotoxicosis • Anemia Diastolic Hypertension: A diastolic pressure >90 mm Hg. Isolated diastolic hypertension is associated with three general disease categories: • Renal disease • Endocrine disorders • Neurologic disorders Treatment of Hypertension: Hypertension is of concern in the ICU when confronting a new MI or a vascular anastomosis and especially following carotid artery surgery.

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The use of the potassium- adrenoceptor blocking agent or the combination of sparing diuretic spironolactone has been shown to im- the direct vasodilator hydralazine and a nitric oxide– prove survival and is discussed below cheap 80mg top avana mastercard. There were fewer deaths among the patients on the combina- Spironolactone tion of hydralazine and nitrates. Patients taking prazosin did not benefit, probably because chronic therapy with Spironolactone (Aldactone) is the only diuretic that has prazosin results in tachyphylaxis. The mechanisms of ac- been shown in a double-blind multicenter prospective tion of prazosin, hydralazine, and organic nitrates are clinical trial to improve survival in CHF. It is unclear at present whether the addition of spirono- The relative ease of administration and superior effi- lactone to a combination of digitalis,ACE inhibitor, and cacy of angiotensin-converting enzyme inhibitors and a -blocker will also confer additional benefit. The demonstration of the sur- the epithelial cells in the late distal tubule and collect- vival benefit conferred by vasodilator therapy resulted 156 III DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM in a paradigm shift in the approach to CHF. The ognized that the way to improve survival in heart failure use of an ACE inhibitor results in the elaboration of was not by directly addressing the weakened heart more kinins and less angiotensin II. Thus, the benefits pump but rather by reversing the inappropriate periph- of ACE inhibitors may derive from their elaboration of eral vasoconstriction that results from neurohumoral more kinins in addition to their inhibition of an- activation. Captopril (Capoten) was the original prototype Efforts to elucidate the mechanisms responsible for product, and it was administered three times a day. Prospective multicenter double-blind tive pathways for forming angiotensin II independent of placebo-controlled clinical trials have repeatedly the conversion of angiotensin I to angiotensin II. Other demonstrated an early and persistent survival benefit cellular enzymes, such as chymases and trypsin, can also with ACE inhibitors in CHF patients. And finally, at least two dis- were found superior to hydralazine and nitrates in a di- tinct angiotensin II receptors have been cloned and se- rect comparison. ACE inhibitors are now clearly the quenced; they are confusingly named the type 1 and agents of first choice in the pharmacological manage- type 2 angiotensin II (AT-1;AT-2) receptors. There are also a number of additional rea- Elaboration of angiotensin II can result in either of sons to use ACE inhibitors.