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Carl Rogers pulse pressure heart rate purchase 2.5 mg bystolic with mastercard, however blood pressure cuff 5 mg bystolic with mastercard, introduced a new technical meaning for the term "empathy blood pressure medication equivalents discount 5mg bystolic with mastercard," using it to describe a particular skill and style of reflective listening (Rogers hypertension united states buy 2.5mg bystolic with amex, 1957, 1959). In this style, the therapist listens carefully to what the client is saying, then reflects it back to the client, often in a slightly modified or reframed form. This way of responding offers a number of advantages: (1) it is unlikely to evoke client resistance; (2) it encourages the client to keep talking and exploring the topic; (3) it communicates respect and caring, and builds a working therapeutic alliance; (4) it clarifies for the therapist exactly what the client means; and (5) it can be used to reinforce ideas expressed by the client. You can reflect quite selectively, choosing to reinforce certain components of what the client has said, and passing over others. In this way, clients not only hear themselves saying a self-motivational statement, but also hear you saying that they said it. Further, this style of responding is likely to encourage the client to elaborate the reflected statement. It is not to be used to the exclusion of other kinds of responses, but it should be your predominant style in responding to client statements. For a client who is ambivalent, reflection of one side of the dilemma ("So you can see that drugs are causing you some problems. You really enjoy using drugs and would hate to give that up, and you can also see that they are causing serious problems for your family and your job. Rather than telling the client how he/she should feel, or what to do, the therapist asks the client about his/her own feelings, ideas, concerns, and plans. Elicited information is then responded to with empathic reflection, affirmation, or reframing (see below). This is done in a structured way, providing clients with a written report of their results ("Personal Feedback Report"), and comparing these with normative ranges. A very important part of this process is your own monitoring of and responding to the client during the feedback. Use reflective listening to reinforce self-motivating 14 statements that emerge during this period. Also respond reflectively to resistance statements, perhaps reframing them or embedding them in a double-sided reflection. It seems like you use about the same amount as your friends, yet here are the results. A sigh, a frown, a slow sad shaking of the head, a whistle, a snort, or tears can communicate a reaction to feedback. If the client is not volunteering reactions, it is wise to pause periodically during the feedback process to ask: What do you make of this? Clients will have questions about their feedback and the tests on which their results are based. For this reason, you need to be thoroughly familiar with the assessment battery and its interpretation. The training videotape "Motivational Interviewing" offers one demonstration of this style of presenting assessment feedback to a resistant problem drinker [See Demonstration Videotapes list at the end of this section. Affirming the Client You should also seek opportunities to affirm, compliment, and reinforce the client sincerely. Such affirmations can be beneficial in a number of ways, including: (1) strengthening the working relationship, (2) enhancing the attitude of self-responsibility and empowerment, (3) reinforcing effort and self-motivational statements, and (4) supporting client self-esteem. Some examples: I appreciate your hanging in there through this feedback, which must be pretty rough for you. Miller, Benefield and Tonigan (1993) found that when problem drinkers were randomly assigned to two different therapist styles (given by the same therapists), one confrontational-directive and one motivational-reflective, those in the former group showed substantially higher levels of resistance, and were much less likely to acknowledge their problems and need to change. These client resistance patterns were, in turn, predictive of less long-term change. Similarly, Patterson and Forgatch (1985) had family therapists switch back and forth between these two styles within the same therapy sessions, and demonstrated that client resistance and noncompliance went up and down markedly with therapist behaviors. The picture that emerges is one in which the therapist dramatically influences client defensiveness, which in turn predicts the degree to which the client will change. This is in contrast with the common view that drug addicts are resistant because of pernicious personality characteristics that are part of their condition. These important client behaviors are more a function of the interpersonal interactions that occur during treatment, although they may result in part from the context in which therapeutic contact occurs.

Colombia produces about 90 percent of the cocaine powder reaching the United States prehypertension stage 1 5mg bystolic overnight delivery. Common street names include: Coca blood pressure chart english bystolic 2.5 mg amex, Coke blood pressure chart 3 year old cheap 2.5 mg bystolic with mastercard, Crack blood pressure 60 over 90 bystolic 2.5mg, Flake, Snow, and Soda Cot Cocaine powder What does it look like? Cocaine is often diluted ("cut") with a variety of substances, the most common of which are sugars and local anesthetics. It is "cut" to stretch the amount of the product and increase profits for dealers. In contrast, cocaine base (crack) looks like small, irregularly shaped chunks (or "rocks") of a whitish solid. Following smoking or intravenous injection, cocaine reaches the brain in seconds, with a rapid buildup in levels. Other effects include increased alertness and excitation, as well as restlessness, irritability, and anxiety. Taking high doses of cocaine or prolonged use, such as binging, usually causes paranoia. The crash that follows euphoria is characterized by mental and physical exhaustion, sleep, and depression lasting several days. Powdered cocaine can be snorted or injected into the veins after dissolving in water. Cocaine is also used in combination with an opiate, like heroin, a practice known as "speedballing. Cocaine users typically binge on the drug until they are exhausted or run out of cocaine. Physiological effects of cocaine include increased blood pressure and heart rate, dilated pupils, insomnia, and loss of appetite. The widespread abuse of highly pure street cocaine has led to many severe adverse health consequences such as: Cardiac arrhythmias, ischemic heart conditions, sudden cardiac arrest, convulsions, strokes, and death In some users, the long-term use of inhaled cocaine has led to a unique respiratory syndrome, and chronic snorting of cocaine has led to the erosion of the upper nasal cavity. Other stimulants, such as methamphetamine, cause effects similar to cocaine that vary mainly in degree. Cocaine hydrochloride solution (4 percent and 10 percent) is used primarily as a topical local anesthetic for the upper respiratory tract. It also is used to reduce bleeding of the mucous membranes in the mouth, throat, and nasal cavities. However, better products have been developed for these purposes, and cocaine is rarely used medically in the United States. Khat is native to East Africa and the Arabian Peninsula, where the use of it is an established cultural tradition for many social situations. Common street names for Khat include: Abyssinian Tea, African Salad, Catha, Chat, Kat, and Oat Khat plant What are its overdose effects? The dose needed to constitute an overdose is not known, however it has been historically associated with those who are long-term chewers of the leaves. Symptoms of toxicity include: Delusions, loss of appetite, difficulty with breathing, and increases in both blood pressure and heart rate Additionally, there are reports of liver damage (chemical hepatitis) and of cardiac complications, specifically myocardial infarctions. This mostly occurs among long-term chewers of khat or those who have chewed too large a dose. Khat that is sold and abused is usually just the leaves, twigs, and shoots of the Khat shrub. Khat is typically chewed like tobacco, then retained in the cheek and chewed intermittently to release the active drug, which produces a stimulant-like effect. Dried Khat leaves can be made into tea or a chewable paste, and Khat can also be smoked and even sprinkled on food. Khat can induce manic behavior with: Grandiose delusions, paranoia, nightmares, hallucinations, and hyperactivity Chronic Khat abuse can result in violence and suicidal depression. Khat can also cause a brown staining of the teeth, insomnia, and gastric disorders. Mexican drug trafficking organizations have become the primary manufacturers and distributors of methamphetamine to cities throughout the United States, including in Hawaii. Domestic clandestine laboratory operators also produce and distribute meth but usually on a smaller scale.

The last benchmarking exercise was done in 2015 blood pressure medication cause weight gain cheap 2.5 mg bystolic, and the next exercise is expected to take place in 2017 arrhythmia blog cheap 2.5 mg bystolic free shipping. The aim of the argenx Employee Stock Option Plan is to establish an ownership culture among employees of the Group pulse pressure 49 order bystolic 5 mg visa, incentivizing its employees pulse blood pressure relationship discount 5mg bystolic, Executive Directors and Non-Executive Directors to contribute to the value of the Company. A summary of the key characteristics of the argenx Employee Stock Option Plan is provided below. In accordance with this benchmarking analysis, the Board has resolved to aim for a compensation of executive directors in the 50th percentile of the compensation offered by the European peer group used in this analysis. In line with the amended remuneration policy discussed above, our Board has amended the current contracts between us and our Executive Directors to be brought in line with the new remuneration policy. An Executive Director will be eligible for an annual cash incentive up to a maximum percentage of his/her annual base salary. Options are granted on the first board meetings following 1 June and 1 December, pursuant to an option allocation scheme established by the Board, which lists the type of employee and the number of options to be granted. The number of options granted to each employee depends on (i) the base option amount set for the position of the employee and (ii) the performance of the employee during the period after which the options are granted, which may influence the base option amount both negatively (in the event of underperformance) and positively (in the event that expectations are exceeded) by preset percentages. The Executive Directors are entitled to customary fringe benefits, such as a company car and a hospitalization plan. In addition, under certain circumstances (such as dismissal without cause), the options granted to Executive Directors will become vested upon such dismissal. The board of directors grants options to the non executive directors on the recommendation of the remuneration and nomination committee. Such option grants are based on an option allocation scheme established by the board of directors pursuant to our Employee Stock Option Plan (as set out in the "Long-term Incentive Plan" above). Pursuant to Dutch law and the Dutch Corporate Governance Code the remuneration of Executive Directors may be reduced and Executive Directors may be obliged to repay part of their variable remuneration to the Company if certain circumstances apply. Pursuant to applicable Dutch corporate law, the Non-Executive Directors will have the power to adjust the value downwards or upwards of any variable remuneration component conditionally awarded to an Executive Director in a previous fiscal year which would, in the opinion of the Non-Executive Directors, produce an unfair result due to extraordinary circumstances during the period in which the predetermined performance criteria have been or should have been applied. In addition, the Non-Executive Directors have the authority under the Dutch Corporate Governance Code and Dutch law to recover from an Executive Director any variable remuneration awarded on the basis of incorrect financial or other data (claw back). In addition, Dutch law prescribes that, in case the value of the Shares or rights to subscribe for such Shares granted by the Company to the respective Executive Directors as part of their remuneration increases during a period in which a public takeover bid is made for the Shares, the remuneration of that respective Executive Director will be reduced by the amount by which the value of the Shares or rights to subscribe for such Shares so granted by the Company to such Executive Director has increased. To the extent the increase in value exceeds the remuneration of the respective Executive Director, the Company shall have a claim against the respective Executive Director for such excess. Similar provisions apply in the situation of an intended legal merger or demerger, or if the Company intends to enter into certain transactions that are of such significance to the Company that the Board requires the approval of the General Meeting pursuant to Dutch law. The Company has one class of securities, ordinary shares, and there are no special rights attached to any of the ordinary shares, nor special shareholder rights for any of the shareholders of the Company. The following major shareholdings fall under the mandatory notice provisions of articles 5:34, 5:35 and/or 5:43 of the Financial Supervision Act: Erasmus Biomedical Fund (2. An optimal risk management needs to contribute to the realization of the following objectives: protecting critical Company assets; giving reasonable assurance on the reliability of financial reporting; monitoring activities in accordance with regulations, laws and codes of conduct; optimizing operational business processes in terms of effectiveness and efficiency. The Board of Directors has delegated an active role to its Audit Committee in the design, implementation and monitoring of an internal risk management and control system to manage the significant risks to which the Company is exposed. As part of this implementation, financial risks have been identified in a risk and control matrix, in which each risk is assessed on its importance based on probability and potential impact. For the key risks of each process, controls or management measures were then defined and in the second half of 2016 the operating effectiveness of these controls have been tested, resulting in areas for improvement, which will be implemented following the typical Plan ­ Do ­ Check ­ Act cycle. Going forward, procedures and controls will continue to be regularly reviewed and tested during audits. It should however be noted that such systems can never provide absolute assurance regarding achievement of company objectives, nor can they provide an absolute assurance that material errors, losses, fraud, and the violation of laws or regulations will not occur. They may be jointly and severally liable for damages to the Company and third parties for infringement of the Articles or certain provisions of the Dutch Civil Code. In certain circumstances, they may also incur additional specific civil and criminal liabilities. This policy contains customary limitations and exclusions, such as wilful misconduct or intentional recklessness (opzet of bewuste roekeloosheid). A Non-Executive Director shall not participate in any discussions and decision making if he has a conflict of interest in the matter being discussed. If for this reason no resolution can be taken by the Non-Executive Directors or the Board as a whole, the General Meeting will resolve on the matter. All transactions in which there are conflicts of interest with Directors shall be agreed on terms that are customary in the sector concerned.

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He is taking bendroflumethiazide for his hypertension and takes meclofenamate regularly to prevent recurrences of his gout blood pressure journal pdf buy 5 mg bystolic fast delivery. On examination arrhythmia blood pressure discount 2.5mg bystolic with amex, he has a regular pulse of 88 beats/minute blood pressure medication recall 2015 cheap bystolic 5mg free shipping, blood pressure of 160/98 mmHg heart attack 60 order bystolic 2.5mg without a prescription, a 4­5 cm raised jugular venous pressure, mild pretibial oedema and cardiomegaly. Question Decide whether each of the following would be appropriate as immediate measures. Pharmacokinetic interactions with digoxin include combined pharmacokinetic effects involving displacement from tissue-binding sites and reduced renal elimination. Orally active positive inotropes other than digoxin include phosphodiesterase inhibitors. These increase cardiac output and may bring some symptomatic benefit, but they worsen survival. Managing hyperkalemia caused by inhibitors of the renin­angiotensin­aldosterone system. Although ischaemia and hypertension may be playing a part, the diffusely poorly contracting myocardium suggests the possibility of diffuse cardiomyopathy, and the raised -glutamyltranspeptidase and triglyceride levels point to the possibility of alcohol excess. If this is the case, and if it is corrected, this could improve the blood pressure, dyslipidaemia and gout, as well as cardiac function. Treatment with a fibrate would be useful for this pattern of dyslipidaemia, but only after establishing that it was not alcoholinduced. It may be physiological, for example in response to exercise or anxiety, or pathological, for example in response to pain, left ventricular failure, asthma, thyrotoxicosis or iatrogenic causes. The importance of first- and second-degree block is that either may presage complete (third-degree) heart block. Severe cerebral underperfusion with syncope sometimes followed by convulsions (Stokes­Adams attacks) often results. This can be difficult to distinguish electrocardiographically from ventricular tachycardia, treatment of which is different in important respects. Sinus bradycardia In sinus bradycardia, the rate is less than 60 beats per minute with normal complexes. This is common in athletes, in young healthy individuals especially if they are physically fit, and patients taking beta-blockers. These may occur in an otherwise healthy heart or may occur as a consequence of organic heart disease. Multifocal ectopics (ectopic beats of varying morphology, arising from more than one focus) are likely to be pathological. In an acutely ill patient, consider the possible immediate cause of the rhythm disturbance. Look for reversible processes that contribute to the maintenance of the rhythm disturbance. Consequently, selection of the appropriate antidysrhythmic drug to use in a particular patient remains largely empirical. Furthermore, this classification does not include some of the most clinically effective drugs used to treat certain dysrhythmias, some of which are listed in Table 32. If the patient is acutely ill on account of a cardiac dysrhythmia, the most appropriate treatment is almost never a drug. Consider the possibility of hyperkalaemia or other electrolyte disorder, especially in renal disease, as a precipitating cause and treat accordingly. Remember that several anti-dysrhythmic drugs can themselves cause dysrhythmias and shorten life. When a person is found to have collapsed, make a quick check to ensure that no live power lines are in the immediate vicinity. Otherwise roll them on their back (on a firm surface if possible) and loosen the clothing around the throat. Tilt the head and lift the chin, and sweep an index finger through the mouth to clear any obstruction. Tight-fitting dentures need not be removed and may help to maintain the mouth sealed during assisted ventilation. If the patient is not breathing spontaneously, start mouthto-mouth (or, if available, mouth-to-mask) ventilation.

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