Answer the following questions for the article A randomized trial of aerobic exercise for major depression: examining neural indicators of reward and cognitive control as predictors and treatment targets: Purpose of the study? Variables (independent vs dependent)? Sampling completed? Methods (quantitative or qualitative)? Instrument? Findings of the research?

Case Study #2: Korean Child diagnosed with Autism Spectrum Disorder Background David Lee (pseudonym), age five years ten months, was diagnosed recently with Autism Spectrum Disorder. His parents, Lisa and Adam Lee followed the recommendation of their pediatrician, Dr. Su, to have David evaluated by the Child Study Team at Children’s Hospital four months after his fifth birthday. Dr. Su was concerned about David’s lack of interactive communication skills and his preoccupation with cars. The Lees believed that David’s lack of age-appropriate socialization was due to being an only child who was cared for by Mr. Lee’s mother on a daily basis. Mrs. Soon Young Lee (pseudonym), a widow, immigrated to the US from Korea three years ago to help care for her grandson while her son and daughter-in-law completed their doctoral and post-doctoral programs in chemical engineering at a local university. Adam Lee, the eldest child, and only son in his family was born in Korea and came to the US for his undergraduate education at age 19, where he met and married Lisa seven years ago. Adam has no interest in returning to Korea to live and is presently negotiating a research and development position for a chemical company in the US. Lisa was born in the US shortly after her parents emigrated from Korea. Lisa is not fluent in Korean. Lisa’s parents now reside in California and visit several times per year but cannot provide daily help to Adam and Lisa. Both parents are 30 years old, and Mrs. Lee is pregnant with their second child. The Lees are practicing Christians, and Mr. Lee’s mother is a Buddhist. David received a complete neurological, cognitive, and communicative evaluation at Children’s Hospital several months ago. Results indicated that David verbally interacted only when spoken to and that he had difficulty with turn-taking and coherence in conversations. Although David used complete sentences and a sophisticated vocabulary about his favorite topic of cars, his speech lacked inflection and sounded “robot-like.” David responded to his name inconsistently and showed little interest in play activities offered to him by either the clinicians or his parents. His use of nonverbal communication, such as gaze and gestures, was also inappropriate for a child his age. The Lees stated that they believed that David’s communication style in Korean is similar to what he exhibited on the day of the evaluation. David demonstrated some repetitive routines, such as stacking and restacking papers and books. David has a special interest in cars and can identify cars by maker and year with precision. He brought several books on cars with him to the Child Study Team evaluation and focused on them even when his parents tried to engage him in conversation. The Lees also commented that David had advanced ability in mathematics and performed at a 5th-grade level. David is expected to enroll in kindergarten this fall, where he can receive speech-language therapy on a daily basis if the parents agree to the recommendations provided by the Child Study Team. He has not attended preschool and has few socialization opportunities with peers other than when he attends church activities. The Lees are concerned about their son’s lack of interaction skills and his recent diagnosis of Autism Spectrum Disorder. They are also concerned because Adam’s mother, who provides most of David’s daily care, denies that there is any type of problem. Mrs. Soon Young Lee, a former middle school mathematics teacher in Seoul, speaks Korean to her grandson and 2 believes that he is a gifted child, not one with a communication difficulty. She encourages David’s interest in both mathematics and cars and praises his precociousness to family in Korea. She told her son and daughter-in-law that they should be glad that their child is “quiet and smart; he does not talk back to adults, and that is good.” She admonished them for “even thinking” that there was something wrong with their first son. Adam also indicated that there is friction with his mother because of his conversion to Christianity and what she considers his “disrespect” for her as the elder in the family. The Lees are dependent on Mrs. Soon Young Lee for financial aid, help in the home, and child care. Mrs. Soon Young Lee has recently lent her son money for a down payment on a home. They are also concerned that Mrs. Soon Young Lee’s criticism of and unwillingness to participate in therapy programs for their son will be detrimental. She has indicated that David should be placed in a school for gifted children and not labeled with Autism Spectrum Disorder or receive any therapies. Mr. Lee states that he wants to do the best for his son but that his mother’s influence in his home is great and that disregarding her wishes will cause greater tension within the family. Mrs. Soon Young Lee has no plans to return to Korea in the near future, as she will provide childcare for the new baby and David.

Discussion Questions 1. What problems might a multi-generational and multi-cultural family such as this have in understanding Autism Spectrum Disorder?

2. Why do you think the grandmother is so averse to her grandson being labeled with Autism Spectrum Disorder and receiving therapy? How much of her perception is cultural? Related to her personality?

3. Suppose you were the clinician working with this child in kindergarten in a public school; how important would it be to work with the grandmother regarding the nature of and treatment for Autism Spectrum Disorder? What are the advantages and disadvantages of enlisting her help or providing information to her?

4. What other issues other than cultural differences toward disability emerge in this case?

NURSING CARE PLAN Acute Pain ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES’ Nursing Assessment Acute Pain related to tissue in- Pain Control [1605] as evi- Mr. C. is a 57-year-old businessman who was admitted to the sur- jury secondary to surgical inter- denced by often demonstrating gical unit for treatment of a possible strangulated inguinal hernia. vention (as evidenced by ability to Two days ago he had a partial bowel resection. Postoperative or- restlessness; pallor; elevated Use analgesics appropriately dees include NPO, intravenous infusion of D51/2 NS at 125 cc/hr pulse, respirations, and systolic Use nonanalgesic relief left arm, nasogastric tube to low intermittent suction. Mr. C. is in a blood pressure; dilated pupils; measures dorsal recumbent (supine) position and is attempting to draw up and reports of 7/10 abdominal Report uncontrolled his legs. He appears restless and is complaining of abdominal pain) symptoms to health care pain (7 on a scale of 0-10). professional Pain Level [2102]

As evi- Physical Examination Diagnostic Data denied by mild to no Height: 188 cm (6′ 3") Chest x-ray and urinalysis neg- Reported pain Weight: 90.0 kg (200 lb) ative, WBC 12,000 Protective body positioning Temperature: 37’C (98.6’F) Restlessness Pulse: 90 BPM Pupil dilation Respirations: 24/minute Perspiration Blood pressure: 158/82 mm Hg Change in BP, HR, R from Skin pale and moist, pupils di- normal baseline data lated. Midline abdominal inci- sion, sutures dry and intact. continued on page 1224 NURSING CARE PLAN Acute Pain continued NURSING INTERVENTIONS* /SELECTED ACTIVITIES RATIONALE Pain Management [1400] Perform a comprehensive assessment of pain to include location, Pain is a subjective experience and must be described by the characteristics, onset, duration, frequency, quality, intensity or client in order to plan effective treatment. severity, and precipitating factors of pain. Consider cultural influences on pain response (e.g, cultural beliefs Each person experiences and expresses pain in an individual about pain may result in a stoic attitude). manner using a variety of sociocultural adaptation techniques. Reduce or eliminate factors that precipitate or increase Mr. C’s Personal factors can influence pain and pain tolerance.

Factors pain experience (e.g. fear, fatigue, monotony, and lack of that may be precipitating or augmenting pain should be reduced knowledge). or eliminated to enhance the overall pain management program. Teach the use of nonpharmacologic techniques (e.g, relaxation, The use of noninvasive pain relief measures can increase the re- guided imagery, music therapy, distraction, and massage) before, lease of endorphins and enhance the therapeutic effects of pain after, and if possible during painful activities; before pain occurs or relief medications. increases; and along with other pain relief measures. Provide Mr. C. optimal pain relief with prescribed analgesics. Each dient has a right to expect maximum pain relief. Optimal pain relief using analgesics includes determining the preferred route, drug, dosage, and frequency for each individual Medica- tions ordered on a prn basis should be offered to the client at the interval when the next dose is available. Medicate before an activity to increase participation, but evaluate Turning and ambulation activities will be enhanced if pain is con- the hazard of sedation. trolled or tolerable. Assessing level of sedation should precede the activity to ensure nece precautions are put in place. Evaluate the effectiveness of the pain control measures used Research shows that the most common reason for unrelieved through ongoing assessment of Mr. C’s pain experience. pain is failure to routinely assess pain and pain relief. Many clients silently tolerate pain if not specifically asked about it. Analgesic Administration [2210]

Check the medical order for drug, dose, and frequency of anal- Ensures that the nurse has the right drug, right route, right gesic prescribed. dosage, right client, right frequency. Determine analgesic selections (narcotic, nonnarcotic, or NSAID) Various types of pain (e.g, acute, chronic, neuropathic, notice based on type and severity of pain. tive) require different analgesic approaches. Some types of pain respond to nonopioid drugs alone, while others can be relieved by combining a low-dose opioid with a nonopioid. Institute safety precautions as appropriate if Mr. C. receives nar- Side effects of opioid narcotics include drowsiness and sedation. cotic analgesics. Instruct Mr. C. to request pr pain medication before the pain is Severe pain is more difficult to control and increases the client’s severe. anxiety and fatigue.

The preventive approach to pain manage- ment can reduce the total 24-hour analgesic dose. Evaluate the effectiveness of analgesic at regular, frequent inter- The analgesic dose may not be adequate to raise the client’s vals after each administration and especially after the initial doses, pain threshold or may be causing intolerable or dangerous side also observing for any signs and symptoms of untoward effects effects or both. Ongoing evaluation will assist in making neces- (e.g. respiratory depression, nausea and vomiting, dry mouth, and sary adjustments for effective pain management. constipation). Document Mr. C’s response to analgesics and any untoward effects. Documentation facilitates pain management by communicating effective and noneffective pain management strategies to the entire health care team. Implement actions to decrease untoward effects of analgesics Constipation is a common side effect of opioid narcotics, and a (e.g, constipation and gastric irritation). treatment plan to prevent occurrence should be instituted at the beginning of analgesic therapy. For Mr. C, constipation could re- sult from his primary condition or his analgesia. Assess for overall GI functioning, possible complications of surgery (e.g., ileus), as well as opioid-induced constipation or NSAID-induced gastritis. NURSING CARE PLAN Acute Pain continued NURSING INTERVENTIONS/SELECTED ACTIVITIES* RATIONALE Simple Relaxation Therapy [6040) Consider Mr. C’s willingness and ability to participate, preference, The client must feel comfortable trying a different approach to past experiences, and contraindications before selecting a specific pain management. To avoid ineffective strategies, the client relaxation strategy. should be involved in the planning process. Elicit behaviors that are conditioned to produce relaxation, such as Relaxation techniques help reduce skeletal muscle tension, which deep breathing, yawning, abdominal breathing, or peaceful imaging will reduce the intensity of the pain. Create a quiet, nondisruptive environment with dim lights and Comfort and a quiet atmosphere promote a relaxed feeling and comfortable temperature when possible permit the dient to focus on the relaxation technique rather than external distraction. Individualize the content of the relaxation intervention (e.g., by Each person may find different images or approaches to relax- asking for suggestions about what Mr. C. enjoys or finds relaxing). ation more helpful than others. The nurse should have a variety of relaxation scripts or audiovisual aids to help clients find the best one for them. Demonstrate and practice the relaxation technique with Mr. C.

Return demonstrations by the participant provide an opportunity for the nurse to evaluate the effectiveness of teaching sessions. Evaluate and document his response to relaxation therapy. Conveys to the health care team effective strategies in reducing or eliminating pain. EVALUATION Outcomes partially met. The dient verbalizes pain and discomfort, requesting analgesics at onset of pain. States "the pain is a 2" (on a scale of 0-10) 30 minutes after a parenteral analgesic administration. Requests analgesic 30 minutes before ambulation. States willingness to try relaxation techniques; however, has not attempted to do so. "The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individu- alized for each client. APPLYING CRITICAL THINKING 1. Is there any other assessment data you would want to gather to 3. What kind of data would you gather prior to having a discus- help plan Mr. C’s pain management? sion with the primary care provider about options for improv- 2. Mr. C. does not have a PCA. What nursing interventions are im- ing pain control in this dient? portant? See Critical Thinking Possibilities in Appendix A

Tina is taken to the nearest emergency department. She is placed on a ventilator and slips into a coma. She is taken to surgery and the gunshot wound is repaired. The surgeon states that with the location of the gunshot wound there is a 50/50 chance that Tina will recover. The surgeon, however, is optimistic and believes that Tina’s chances are likely a little better, although he cannot give an exact percentage. The surgeon is not sure how much brain function Tina will have, although she will have some. Tina remains on a ventilator.

Tina did not have an advanced health directive. Like many, it was one of the things that Tina had meant to do, but had not gotten around to doing. Emily discovers a handwritten note from Tina. In the note, Tina stated that life with incurable cancer wasn’t worth living. She asks the doctors to “finish” her suicide by withholding life support, such as a ventilator, in the event that she survived her suicide attempt. Tina’s family wants Tina taken off the ventilator. The physician, however, is reluctant to remove the ventilator because he is concerned that he would be assisting in a suicide, which is prohibited by state law. What do you believe should be done?

Part 1 -Introduction of evolved scenario with clinical judgment framework application and issue to address (20% b. Part 2 – Evidence-based alternatives approach for issue and decision for practice situation (20%) c. Part 3 – Application of communication models to advocate for safe and ethical clinical decision made (20%) d. part 4 – Entire group engagement with class – Interactive dialogue with class – questions and answers (20%) (NOTE: if you (as an individual) do not attend other group presentations (weeks 12-13-14) you will not receive this 20% (does not affect all members of group) e. audio/ visual presentation (20%)