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Runninghead:Familypreparednessandendoflifesupport

Davidson M.K.(2011) Evidence-Based Practice Guideline Family

Preparedness and End-of-Life Support Before the death of a nursing Home Resident
Ladonia Bonner
823-016-746
Humber College, Practical Nursing
Nurs 260: Practical nursing Theory 2
February 25, 2014

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In researches conducted, 20% of the residents in United States die in nursing home than in their
homes or hospitals (Davidson, 2011,p.11) .In reality, Nursing Homes are defacto hospices and
should not be viewed only as a place for rehabilitation for the terminally ill. Failure to recognize
often lead to nurses giving poor end-of life-care, both leaving the family and the nurses
themselves unprepared when death of the resident occurs, the grieving process is then made
unbearable. The journal article: Evidence -Based Practice Guideline Family Preparedness and
End-of-life Support before the Death of a Nursing Home Resident is evaluated in this essay with
aim of enhancing family preparedness and end-of-life support. Within this article, three major
elements were consistent which this essay will expound on. The three elements are as listed:
Staff development-educating the staff on the dying process. The second is communication;
between family and nurses, the health care providers and between nurses and the patient. The last
element is: recognizing that nursing homes are hospices defacto-highlighting this fact more
resources can be allocated properly in the nursing homes, so adequate end-of-life care be given.

Davidson states that successful and consistent implementation of family preparedness and endof-life support depends on the knowledge, skills, and abilities of frontline workers. The need to
improve training in nursing home staff, the article suggests that nurses be educated in
communication skills, dying trajectory, death and bereavement, culturally sensitive end-of-life
care, clinical indicators of mortality. Staff should be educated to use 'clinical indicators of
mortality' such as; weight loss, low body mass index, increasing dependence with activities of
daily living and low respiratory infection (Davidson, 2011, pg.13)
However, according to International affairs and Best Practice Guidelines ,2011, End of life care
During the Last days and hours studies conducted identified fatigue, pain, lack of energy,

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weakness and appetite was were frequent symptoms in 50% of individual in the last two weeks
of life.
I agree with the articles stance on training of the nursing staff in order for the nurses to impart
effective end-of-life care, for nurses to be confident and competently execute end-of-life care
while preparing and educating family before the death of the resident the staff needs to be
developed in the dying process. This will enhance their professional autonomy and their quality
assurance. Nurses need to be educated with the key notions of the dying process. One key notion
is to be educated with the living-dying interval, which is a conceptual model that explains the
process of dying. This leads front line nurses to identify the dying trajectories which classes the
course of dying whether the process will advance, be imminent or not. The model has an acute,
chronic and terminal phase. Acute phase is the peak of stress, the dying residents and familys
life is thrown into uncertainty. In the chronic phase, the uncertainty settles and normalcy takes
over, however, in the terminal phase the physical strength is diminished and the person has no
energy to do activities of daily living. Treatment of physical and psychological pain, medication
may be granted to relieve pain however medication alone is not sufficient, but listening to the
patient express his/her wishes or thought is just as effective. Nurses need to be aware of the
patients culture concerning as end-of-life care or support: if religion is important, gentleness of
touch, closeness are acceptable, belief in afterlife, if they openly talk about death and the type
and content of communication.
According to International Affairs and Best Practice Guideline 2011 End-of-Life Care during
the Last Days and Hours evidence suggests more education is needed in both undergraduate and
post registration life due to the complex care given to the family or patient during end-of-life
care. Nurses especially novices are ill equipped and lack knowledge and competence required.

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Runninghead:Familypreparednessandendoflifesupport

Davidson indicated that lack of communication among decision makers and failure to agree on a
course for end-of-life care are two common obstacles to implementing palliation for nursing
home residents. Communicating clearly with health professionals is a major predictor of family
preparedness for end-of -life care. The article explains that Registered Nurses and Licensed
Practical Nurses should refrain from using unclear, unambiguous language, avoiding end-of-life
euphemisms such as 'not doing well', 'wearing out' or 'may not better. Colleges of Nurses of
Ontario Guiding Decisions about End-of-Life Care 2009 states that a nurses communicate goals
of care and treatment by identifying and using appropriate communication techniques when
discussing treatment and end-of-life issues with client and family.
I coincide that nurses need to be equipped in their communication skills as end-of-life care and
preparing family members and the dying resident of the axiomatic death is an emotional task.
Nurse-patient communication is important as long as the patient is able to understand all the
information given to them leading to an informed decision made. Nurses need to communicate
with the residents family in case of the patient being unable to make decisions for themselves in
such cases the eldest of the family is placed in charge of decision making or the patient choose a
substitute decision maker for the time they become incapable of making decisions.
Communication between the nurses or health care providers is important to achieve the 'good'
death the family and patient is expecting and for the patient to die in dignity. Nurses should
ensure that all the client's wishes and plans are arranged. Whether to continue or discontinue the
treatment, or what treatment is appropriate for the patient at this time, the making of a will,
power of authority or substitute decision maker. Also nurses have the responsibility of following
up if all the wishes of their patient are in placed as they were arranged to be.

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Runninghead:Familypreparednessandendoflifesupport

College of nurse of Ontario 2009 Guiding Decisions about End-of-Life care states that nurses are
to advocate for the creation or modification of practice-setting policies and procedures to support
client choices during treatment and end-of-life care. The College policies extend to ongoing
communication about end-of-life care wishes and implementing the clients wishes by reviewing
the clients plan of treatment including resuscitation wishes. Nurses are expected to
communicate any changes in clients wishes to the interprofessional team.
Empirical research conducted has shown that nursing homes give palliative care to 30% of their
clients according to Family Preparedness and End-of-Life Support before Death of a Nursing
Home Resident. The article explains that nursing homes funding, regulation, and policies are
closely tied to rehabilitation and maintenance of function activities. Nursing homes staff are at a
dissonance is trying to conduct resident care in order to achieve optimal funding for the home
and wanting to provide optimal palliative care for dying residents that does not include
rehabilitation or maintenance of function (Davidson,2011,pg.15)
The government, funding agencies need to recognize that nursing homes and long term
facilities are indeed hospice defacto and not so much a rehabilitative or functional maintenance
facility for all of its residents. With this recognition money may be allocated properly in the
health care system to provide more resources for these nursing homes to deliver efficient
palliative care. More focus will be placed on training nurses in delivering end-of-life support and
preparing family for the death of their loved one.
In the article, Death in Nursing Home: Residents, Family and Staff Perspective, family members
believed that end-of-life providers are trying to meet needs of residents but recognize that
systems and services for older adults concerning end-of-life needs to be improved. The residents
receiving end-of-life support, the familys viewed the care as being insufficient, a consequence

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of having insufficient and poorly trained facility staff. Within the same article nurses admit that
inadequate knowledge, skill levels, inadequate staffing, high staff turnover and physician
disregard for end-of-life issues are obstacles faced by nurses in giving end-of-life care.
In conclusion, I concur with the arguments presented by the journal article entitled Family
Preparedness and End-of-Life Support before the Death of a Nursing Home Resident. Reading
this article has opened my eyes to the extensive care and support that a dying resident and their
family need. Through my further research after reading this article I have seen that the support
and family preparedness concerning end-of-life care is lacking. This article educated me on ways
that we can enhance family preparedness and end-of-life support in nursing homes through tens
points, however, I choose three main points mentioned in detail above to carry out the articles
point of view. In essence, the article suggests that for effective end-of-life support to be given to
patient and family the staff must be educated in delivering effective palliative care, medication,
culture and the dying process. The staff should be able to communicate so as the enhance
decision making. Lastly, government and funding agencies need to allocate funds properly in the
nursing homes to attend to palliative care and not only rehabilitation as many residents will not
attain this.

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References
College of Nurses of Ontario, 2009, Guiding Decisions about End-of-Life Care
http://www.cno.org/Global/docs/prac/43001_Resuscitation.pdf
International Affairs and Best Practice Guideline, 2011, End-of-Life Care during the Last Days
and Hours
http://rnao.ca/sites/rnao-ca/files/End-of-Life_Care_During_the_Last_Days_and_Hours_0.pdf
Carlson, Alison L, APRN, MS, Np-C. Journal of Gerontological Nursing 33.4
41. Death in the Nursing Home: Resident, Family, and Staff Perspectives

(Apr 2007): 32-

http://search.proquest.com/docview/204151928

Davidson M.K., MN,BSN.Journal of Gerontological Nursing Vol.37 ,(Nov.2011) EvidenceBased Practice Guideline Family Preparedness and End-of-Life support Before the Death of a
Nursing Home Resident

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Runninghead:Familypreparednessandendoflifesupport

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Runninghead:Outline

Name: Ladonia Bonner

Student #:823-016-746
Title: Experiencing A Health Challenge: The Effects on clients
Course Title: Practical Nursing Theory 3 NURS209 (360)
Humber College ITAL

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Runninghead:Outline

Summary
Beautiful Mind (2002) is an autobiography on the life of John Nash a renowned Mathematician.
The movie shows us the struggle Nash goes through as a mathematics student at Princeton
University, where he desires to make valuable mark in the world mathematics. After graduating,
Nash is approached by the government to break codes of their enemies and to reveal their plot
against Untied States of America. During this time John Nash, who is now a teacher, begins an
affair with his student, Alicia, who later becomes his wife. As the movie unfolds, what John
Nash thought to be true of his private but dangerous mission of unveiling the enemies plans, all
turned out to be a figment of his imagination. He was diagnosed with schizophrenia and was
admitted into mental health institution by his wife Alicia. After receiving treatment and being
released John Nash was faced with decreased sexual libido and other problems. This led to him
stop taking his drugs which caused his symptoms to reappear. His wife, however, suggested to
John, that in order to recover he should go back to his previous activities before the illness,
teaching and to reject the delusions. After years of struggle, he triumphed over his tragedy and
later in his life went on to win the Noble Prize.
Three physical effects John Nash experienced that were caused by Schizophrenia were his
unkempt appearance, tremors and stiff walking of limping. These are signs and symptoms of
schizophrenia (referred to as negative symptoms-these symptoms reflect a loss of functions) or
side effects of medication used to treat the disease. His unkempt appearance is a sign and
symptom of untreated schizophrenia which leads to a disruption in the persons normal daily
activities; due to his hallucinations or delusions preventing him from carrying normal activities
example bathing or dressing. His tremor may be due to extrapyramidal symptoms may develop
as a side effect of the drugs used to treat schizophrenia (The Canadian Journal of Psychiatry,

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Runninghead:Outline

2005). His limping and abnormal gait may be due to decrease or loss of dopamine levels within
his brain. This results in tremors, muscle rigidity, postural instability. The severity of these
symptoms shows the marked level of dopamine depletion in the brain. (John Hopkins Medical,
2014).
John Nash delusions and withdrawal symptoms are psychosocial effects of schizophrenia. His
delusions are considered positive effect of the disease. It is classified as positive as they are not
seen in healthy people (The Canadian Journal of Psychiatry, 2005).John Nash experienced
delusions, as he thought he was hired to solve plans of his countrys enemies. He also thought he
was targeted and his life was in danger due to his involvement in this fictitious case.
Withdrawing himself or seeking isolation is another symptom John Nash exhibited and this may
be due to his delusions. Alicia, John Nashs wife, experience stress due to her husbands illness.
She couldnt cope with admitting him to a mental clinic as it felt like betrayal; she found it
difficult to cope as the provider of the household with minimum wage when he got sick and the
effects of the medication that decreased his libido.
One priority area for holistic nursing care is John Nashs delusions. Delusions are alterations in
thought context. Delusions are false fixed beliefs that cannot be corrected by reasoning or
evidence to the contrary (Canadian Psychiatric Mental health Nursing, 2014). Treating his
delusions will reorient John Nash on the real reality and other symptoms that he is exhibiting
may dissipate. His delusions are the cause of his disorganized behavior, resulting in his unkempt
look. Treating his delusion would also help his withdrawal or isolation symptoms. This is the
aim of cognitive behavioral therapy which is a form of treatment for patients with schizophrenia.
Cognitive behavioral therapist aim to have the patients speaks about their delusional episodes;
understand how they arrive to this conclusion and in an attempt to eliminate the triggers, whilst

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decreasing the positive symptoms. Therapist believes that schizophrenics internalize comments
on their self-worth, biases or things completely irrelevant to them, combine with stress this leads
to delusions of hallucinations. Studies have shown that schizophrenia is caused by biological,
environmental factors. However, studies have shown that stress may cause schizophrenia. This
delusions and hallucinations can be treated the patient to reorient the patient to reality and
decrease other symptoms that accompany the disease. (Cognitive Behavior Therapy for people
with Schizophrenia, 2009)
To help the client with the area of priority these three nursing interventions that can be
implemented to maintain optimal mental level for the patient. Providing appropriate medication
therapy such as antipsychotic drugs to help reduce the symptoms of schizophrenia in this case
delusion. Antipsychotics are the recommended drugs to treat schizophrenic patients. They are
classified into two groups;first generations (typical-blocks dopamine) or second generation
(atypical-blocks dopamine but also affect serotonin level) of drugs. Second generations
antipsychotics are used preferably today, as they have more effective in treating the positive
symptoms of schizophrenia and they are accompanied by fewer side effects which are
manageable, this is usually the problem with the first generation antipsychotics. A process of
dosage titration and combination is needed to arrive at the correct medication regimen for the
patient, as to decrease its effects on the activities of daily living. Administering medications will
require frequent monitoring of the patient, to see how they adhere, tolerate and its therapeutic
effects (Canadian Journal of Psychiatry, 2005). A second line of intervention move him to a
more quiet, and less stimulating (low lighting, less noise, less dcor),rationale, anxiety increases
in stimulus filled environments, the patient may be perceived as a threat because of suspicions
and may get agitated (Nanda Nursing Interventions,2012). Reorienting the client daily to time,

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place, where you are, what real and what is not or by keeping a regular routine is another
intervention that can be implemented. Understand and explore your patients delusional
experiences; however it is important to clarify misinterpretations of the environment and gently
suggest as tolerated a more reality based perspective. As a blunt attempt to dissuade the patient
may lead to their retention of the delusion (Canadian Psychiatric Mental Health
Nursing,2014).Keeping a regular routine increase social inclusion and promotes hope among
clients while its reduces delusional episodes; as client may perceive as being in danger due to
changing faces and environments. (Gerontological Nursing and Health Aging, 2010)
Collaboration with other inter-professionals health care members is important in the treatment of
schizophrenic patients. Cognitive therapists, are professionals that could be recommended to
collaborate with. Therapist talk to the client about their delusional experiences; and with the
patient, develops a model of the causation of the experiences (The Lancet, 2014).This a nonpharmological way to treat delusions that are positive symptoms of schizophrenia. According to
The Lancet (2014), a randomized controlled trial in the United Kingdom was conducted at two
clinics, where schizophrenic patients who did not want to take antipsychotic medications were
selected and was randomly assigned to only receive cognitive therapy while the other percentage
received antipsychotic medication and cognitive therapy for treatment of the disease. At the end
of the trials, the study concluded that cognitive therapy reduced psychosis symptoms and seemed
safer and a more acceptable alternative for people suffering from schizophrenia who decided not
to take antipsychotics. This is the aim of cognitive behavioral therapy which is a form of
treatment for patients with schizophrenia. Cognitive behavioral therapist aim to have the patients
speaks about their delusional episodes; understand how they arrive to this conclusion and in an
attempt to eliminate the triggers, whilst decreasing the positive symptoms. Therapist believes

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that schizophrenics internalize comments on their self-worth, biases or things completely

irrelevant to them, combine with stress this leads to delusions of hallucinations. This delusions
and hallucinations can be treated the patient to reorient the patient to reality and decrease other
symptoms that accompany the disease (Cognitive Behaviour Therapy for People with
Schizophrenia, 2009)
Recreational Therapist may be recommended as they focus on the clients support system as well
as their environment. Therapist addresses primary psychiatric symptoms, prevention and mental
health maintenance and strengthening of psychosocial support. Recreational therapist
interventions focus on symptoms reduction, education addressing social skills, stress
management and health maintenance, adventure challenges and family interventions (American
Therapeutic Recreation Association, 2000,pg.1).One of the aim of the therapy is decreasing
manifestation of stress and depressive symptoms such as tension, sleep disturbances, negative
thinking and anxiety resulting in decreased psychiatric problems. Collaboration with a
Psychiatrist is important. Psychiatrist uses various interventions in treating schizophrenia
successfully. Apart from prescribing medications, psychiatrist do psychosocial interventions to
improve social skills, educate the family, treat substance abuse and recommend peer support. (
PsychCentral,2014).
Individuals suffering from schizophrenia can seek resources within their communities that
provide help with treatment as well as maintenance of the disease. They can also receive more
information about the disease to increase their awareness and knowledge among client and their
family members. Center for Addiction and Mental Health (CAMH) located at 101 Queens Street
West, Toronto Ontario M6J 1H4 and can be contacted at 416-595-6111, it is TTC accessible and
is open from 9-5 pm. CAMH is a Canadas largest mental and addiction teaching hospital. They

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propose to transform lives by their six directions(Enhance recovery by improving access to

integrated care and social support, earn a reputation for outstanding service, accountability and
professional leadership, build an environment that supports recovery, ignite discovery and
innovation, revolutionize education and knowledge exchange, drive social change).For clients
with schizophrenia they inform the client and also treat patients using biological treatments
(medications) and psychosocial interventions (counseling, case management) (Center for
Addiction and Mental Health,2012) .Canadian Mental Health Association located on 2301-180
Dundas Street West, Toronto, Ontario, M5G 1Z8.This facility can be contacted via
email:info@ontario.cmha.ca or webpage: http://www.ontario.cmha.ca or phone to 416-977-5580.
This facility is TTC accessible. CMHA sets their goals to builds capacity, implement policy,
provide service and develop resources. They provide supports and services for clients and
families (Canada Mental Health Association, 2014).
Schizophrenia is a mental illness that affects the interaction between the individual and the
world. John Nash a famous Mathematician suffered from schizophrenia as seen in his
autobiography Beautiful Mind. He displayed both negative symptoms (limping, tremors,
unkempt appearance and isolation or withdrawal) as well as positive symptom (delusions) of the
disease. Three nursing intervention that can help manage his priority area of care (his delusion)
are placing client in a low stimulus environment, reorient client to time day, keeping the same
routine and administering antipsychotics. Collaboration with the inter-professional team is
important. Collaboration among cognitive therapist, psychiatrist and recreational therapist is
important as they provided individualized care in treating delusions. Community resources such
as Canada Mental Health Association and Center for Addiction and Mental Illness are facilities
individuals and families can go to seek treatment, information about the schizophrenia.

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References
American Therapeutic Recreation Association: Recreation Therapy [PDF]. Retrieved October 2,
2014 from
http://humanservices.ucdavis.edu/resource/uploadfiles/4E%20Recreational%20therapy.pdf
Canadian Mental Health Association: Ontario Division. Retrieved October 2, 2014 from
http://www.cmha.ca/branch_locations/ontario-division/
Center of Addiction and Mental Health: Contact Us. Retrieved October 2, 2014 from
http://www.camh.ca/en/hospital/visiting_camh/contact_us/Pages/default.aspx
Howard R. (2001) A Beautiful Mind [movie], Los Angeles: DreamWorks Pictures
http://megashare.info/watch-a-beautiful-mind-online-TWprMU1RPT0
John Hopkins Medicine (2014). Parkinsons Disease. Retrieved from November 21, 2014 from
http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/movement_disorders/c
onditions/parkinsons_disease.html
Morrison, A. (2009, December). Cognitive Behavioral Therapy for people with Schizophrenia.
Retrieved from November 13, 2014 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811142/
Nanda Nursing Interventions (2012). Retrieved November 21, 2014 from http://nandanursinginterventions.blogspot.ca/2012/03/nursing-interventions-for-schizophrenia.html
The Canadian Journal of Psychiatry (2005). Clinical Practice Guideline: Treatment of
Schizophrenia vol.50, number 13.Retrieved November 21,2014 from https://ww1.cpa-

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apc.org/Publications/Clinical_Guidelines/schizophrenia/november2005/cjp-cpg-suppl105_full_spread.pdf
Halter,M. (2014).Canadian Psychiatric Mental Health Nursing:A Clinical approach [1st
Edition].Elsevier Canada
Tartakovsky M. (2014) Treating Schizophrenia Successfully. PschyCentral. Retrieved October
2, 2014 from http://psychcentral.com/lib/treating-schizophrenia-successfully/00018927
Touhy,T., Jett,K. (2010).Gerontological Nursing and Healthy Aging. Elsevier Canada
The Lancet: Cognitive Therapy for people with schizophrenia spectrum disorders not taking
antipsychotic drugs: single-blind randomized trial. Retrieved October 2, 2014 from
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62246-1/abstract

Ladonia Bonner
Class: Psychology
Topic: Classical Conditioning

Learning is defined by psychologist as a relatively permanent change in behavior, knowledge,

capability, or attitude that is acquired through experience and cannot be attributed to illness,
injury, or maturation (Wood E.S., Wood E.G., Boyd D., Wood E., Desmarais S.(2011) The World
of Psychology 7th Edition). Therefore, we recognize our environment, the way we interpret the
incoming stimuli, and therefore the way we interact, or conduct ourselves. John B. Watson
(1878-1958) was the first to study how the process of learning affects our behavior, and he
formed the school of thought known as Behaviorism. There are three basic forms of learning:
classical conditioning, operant conditioning and observational or cognitive learning. Within this
essay we will be focusing on explaining classical conditioning, a real life experience will be
given to explain how classical conditioning theory works. The classical conditioned diagram will
be used to further illustrate how the classical condition theory works.
Classical conditioning is one of the easiest forms of learning of the three mentioned above. It is
learnt through association, between one stimulus and another. It is a process through which a
response previously made only to a specific stimulus is made to another stimulus that has been
paired repeatedly with the original stimulus. A stimulus is any an agent, action, or condition that
elicits or accelerates a physiological or psychological activity or response. This was discovered
by Ivan Pavlov where he placed a small incision in the sides of each of the dogs mouth. He
attached tubes so that the flow of saliva could be diverted from the animals mouth, through the
tube, and into a container, where the saliva could be collected and measured . Palvov originally
wanted to collect the saliva that the dog natural secreted in response to food placed in the mouth.
But he saw that the dog responded to salivated before he was given the food. He observed that
the dog salivated to the rattling of the dishes, when the dog saw the attendant who feed them or
when they heard footsteps. The dog had learnt how to associate the footsteps, the rattling of the

dishes and the attendant to food and would salivate whenever he saw or heard them. (Wood E.S.,
Wood E.G., Boyd D., Wood E., Desmarais S. (2011) The World of Psychology 7th Edition.
There are three stages or processes to achieve classical conditioning. The first stage which can be
termed, before conditioning stage is where a stimuli is given and an unconditioned response is
achieved that is unlearned or natural. Therefore the individual has not learnt anything at this
point. This stimulus is termed as the unconditioned stimulus and the response as unconditioned
response. Example of this is every time you cut onion, the juice from the onion makes your eyes
teary. The second stage of classical conditioning can be termed as, during classical conditioning.
In this stage a neutral stimulus is brought into play that provokes no response from the
individual. However, after repetitively pairing the the neutral stimulus, with the unconditioned
stimulus, it evokes the unconditioned response. The neutral stimulus is now termed as
conditioned stimulus. The final stage can be termed after conditioning; in this stage the now
conditioned stimulus (former neutral stimulus) being associated with the unconditioned stimulus
for a period of time produces a conditioned response. Pavlov describes this response as learned
and thus classical conditioning as occurred. Example, the dog would hear a tone (neutral
stimulus) that evoked no response. However we repeatedly played the tone (neutral stimulus),
then gave the dog the food shortly after (pairing) the dog would salivate. After a period of time,
when the tone (neutral stimulus becomes conditioned stimulus) alone was played, the dog began
to salivate even before the unconditioned stimulus (food) arrives gives a conditioned response.
Any similar tone would play to the original one that was associated with the unconditioned
stimulus. However the dog would salivate to the several similar sounds that were played. He had
not learned to distinguish between the sounds, he however generalized.

I experienced classical conditioning within my childhood, I was around the age of 5.My mother
would travel a lot and so my father had the responsibility of taking care of us such as, cooking us
dinner, taking us to school and back home and so on. So every day he would pick us up from
school and bring us to this restaurant where we would eat chicken nuggets, because that was my
favorite at the time. When you were near you could smell the aroma of the food being prepared
and I would start to get hungrier and salivate more. At this point the smell of the food being
prepared would be the unconditioned stimulus. When I would smell the aroma of fried food
emitting from the restaurant I would get hungrier and salivate more, this is the unconditioned
response. This occurred naturally, no learning took place. However, I realized that this place
where I would get my favorite food (chicken nuggets, the unconditioned stimulus) had a big
yellow M on the front of it. My dad would always turn into the parking lot in front of the
restaurant with the big yellow M (neutral stimulus). So every time I would see a big yellow M
anywhere I go, even if I had just eaten I would get hungry and salivate because it was associated
with my favorite food. Classical conditioning has occurred.
I will now demonstrate my classical conditioning in the form of a diagram.
Before Classical Conditioning
Neutral Stimulus
Big yellow M sign in front of restaurant

No salivation

During Classical Conditioning

Conditioned Stimulus

Unconditioned Stimulus Unconditioned response

Big yellow M sign in front of restaurant

Chicken Nuggets

Salivation & hunger

After Classical Conditioning

Conditioned Stimulus
Big yellow M sign in front of restaurant

Conditioned Response
Salivation and hunger

Generalization took place for me with the aroma of the food. Whenever I would pass any other
restaurant that had aroma emitting from it, similar to the restaurant with the big yellow M sign I
would start salivating and get hungry. If my dad would stop I would complain and he would tell
me that it was not the place where we get my chicken nuggets.
In conclusion, classical conditioning is one of the easiest ways to learn of the three
(observational and operant conditioning). Classical conditioning learning is accomplished
through associative learning. It is a process through which a response (unconditioned response)
previously made only to a specific stimulus (unconditioned stimulus) is made to another stimulus
(neutral stimulus through continuously pairings with unconditioned stimulus became conditioned
stimulus) that has been paired repeatedly with the original stimulus. While operant conditioning
is a type of learning in which the consequences of behavior tend to modify that behavior in the
future. Observational learning is learning by observing the behavior of others and the
consequences of that behavior, learning by imitation.

Reference
Woods E.S. et al (2011) The World of Psychology 7th Edition,Toronto,Pearson

Runninghead:rationale

Name: Ladonia Bonner

Student #:823-016-746
Title: Rationale for the Pathways Chosen
Course Title: Complex Issues and Patient Safety

Runninghead:rationale

The scenario given was of a 3 month old male infant, born with cleft lip, eight hours postoperation repair of the left side upper cleft lip. Vital signs post-operation: temperature: 36.8C,
pulse:-184, respiration rate: 22, blood pressure: 82/50 and oxygen saturation is 93%. The infant
is on IV normal saline @ 12mls/hour in the RA. The child is alert, fussy, reflexes normal.
Incision is swollen and serosanguinous drainage present. Cleft lip is commonly occurring congenital
midline fissure or opening in lip due to failure of the primary palate to fuse it occurs during embryonic
development. Genetics or environmental factor causes the development of cleft lip teratogen, alcoholic,
smoking, anticonvulsants, and steroids. Cleft deformities occurs due to genetic defect in cell migration
that results in the failure of maxillary and premaxillary processes to come together in the 3 and 12 weeks
of embryonic development.

The pathways that were chosen were both pathophysiological: Risk for infection and
Ineffective breathing pattern. These two pathophysiological pathways were chosen based on
priority, which is more important to the client. Prioritization is deciding what needs or problems
require immediate attention and which ones that can be delayed as they are not urgent
(Silvetre,2008).Prioritization is important as it saves time, energy and reduce burnout for nurse,
it also increase patient discharge time, recovery speed and effective use of resources. The
pathway chosen as highest priority is ineffective breathing and the clinical manifestation under
this pathway was that of the oxygen saturation being a low 93%.this essay will highlight the
rationale of the decision chosen to focus on the low oxygen saturation.
Pathophysiological priority

Breathing is essential as it provides our bodys vital organs with the oxygen, which these organs
need to survive- organs such as the brain, heart, and lung and so on. Ineffective breathing can
be results of breathing too fast (hyperventilation) or breathing too slow (hypoventilation). The

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outcome being not enough oxygen is being absorbed in the body and not enough carbon dioxide
being removed. The patient may become lethargic, have decreased levels of consciousness and
worst cases die. Evidence to support that the child had ineffective breathing was the low oxygen
saturation which was 93%, the infants irritability. Maslows hierarchy was developed in order to
see what motivates people to achieve certain needs. The individual would have to achieve the
lowest rank of need before moving on to achieve the basic needs above it before eventually
achieving self-actualization which is the ultimate goal. He listed physiological, safety, social,
esteem and self-actualization as categories of his hierarchy. Within the physiological category
breathing is an essential basic need that the individual need to accomplish in order to achieve
their goal and move on to the next step (Potter and Perry, 2014). Breathing is also listed as the
ABCs that should be given priority on in the all cases of patient care (Wendy Chow,2015).
British Medical journal (1998), states that airway, breathing and circulation are pre-requites to
life and their dysfunctions lead to common denominators of death.
Clinical Manifestation or Complication
As breathing is listed in the ABCs, it suggests that it is critical to one survival. Clinical
manifestation that was chosen as the highest priority was the low oxygen level of the infant,
which was 93%. A 93% oxygen level in an infant without prior respiratory conditions calls for
concern. The clinical manifestation is related to ineffective breathing with evidence of a low
oxygen saturation level. This indicates that the infant is not breathing properly to inspire enough
oxygen needed for gaseous exchange. Another reason would be that the infant could be in pain
or is feeling sore at the incision site. It has been eight hours post-operation, with no information
of analgesics being administered. According to Ward and Karan (2002), pain may affect oxygen
levels as well as how the client breathes. Pain increases ventilation by resetting resting

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ventilation without affecting the chemoreflexes. (Ward and Karan, 2002) .The child low
oxygenation leads to impaired cognitive development, being the client is an infant it makes him
more susceptible to impaired cognitive development if the oxygen saturation is not corrected or it
continues to drop. Low oxygen level also leads to high risk of morbidity; this is due to the lack of
vital organs getting oxygen that is vital for their survival and function (Oxygen saturation and
cognitive performance, 2002).
Nursing interventions
Provide oxygen saturation via nasal cannula starting at the lowest dose/percent is an intervention
listed under the clinical manifestation of low oxygen saturation. It is related to low oxygen level
as it a form of oxygen therapy that is used to adjust or supply the client with additional oxygen if
they are incapable of breathing in enough on their own. The nasal cannula is the low flow device
that provides oxygen saturations that vary with the patients respiratory pattern.it is used for
individuals with minor breathing problems (Potter and Perry, 2014). Intervention two, assessing
respiration rate and depth will tell us if the patient is breathing too fast or too slow, leading us to
appropriate intervention. It is related to low oxygen saturation, as improper breathing affects
gaseous exchange (how much oxygen is inspired or how much carbon dioxide is exhaled).
Assessing the depth and assessing the respiration after oxygen therapy indicates whether the
intervention was successful or if the desired outcome was achieved, and if all the lobes of the
lungs were involved in the ventilation process (Potter and Perry,2014).Applying pulse oximetry
to monitor oxygen saturation and pulse continuously- this is a useful tool in assessing the oxygen
saturation within the blood. The value it gives tells the health care team of how much oxygen is
in the clients blood. How effective they are breathing, how effective was the therapy and the
relationship between breathing and perfusion which affects gas exchange (Chandler, 2002).

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Repositioning the infant ensure to promote lung expansion is the fourth intervention listed.
Promoting lung expansion helps in preventing atelectasis, mobilizes secretions, decrease work
for breathing, and increase lung volume. This is essential as it prevent further complication of
that is related to ineffective breathing. This allows the lungs to remain active even the lower
lobes where problems tend to arise ( Potter and Perry,2014).As stated before, due to the age of
the infant, he is at a high risk of developing complications due to the fact that its structures are
adequately developed as yet. The fifth intervention is to do an arterial blood gas test on the
infant. This test informs the health care team of the pressure of oxygen, carbon dioxide as well as
the ph in the blood that came from the infants artery. It measures the how well your lung move
oxygen well into the blood and remove carbon dioxide (K. Roger and K. McCutcheon,2013).
In conclusion, cleft lip is commonly occurring congenital midline fissure or opening in lip due to failure
of the primary palate to fuse it occurs during embryonic development. Genetics or environmental factor
causes the development of cleft lip teratogen, alcoholic, smoking, anticonvulsants, and steroids. Surgery
is used to correct the abnormal facial structure. Prioritization is deciding what needs or problems

require immediate attention and which ones that can be delayed as they are not urgent
(Silvetre,2008).Prioritization is important as it saves time, energy and reduce burnout for nurse,
it also increase patient discharge time, recovery speed and effective use of resources. The
pathway chosen as highest priority is ineffective breathing and the clinical manifestation under
this pathway was that of the oxygen saturation being a low 93%.Interventions such as putting on
a nasal cannula to give supply of oxygen to client, assessing respiration rate, depth, repositioning
the client can be used to aid in the helping the client breathe better or to prevent further
complications.

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Reference
Anderson, Jan, et al(July,2002). Oxygen saturation and Cognitive Performance. Retrieved form
Humber Library Database, on March 15, 2015.
search.proquest.com.rap.ocls.ca/docview/218941147?pq-origsite=summon.

British Medical Journal (June, 1998). Airway, Breathing and Circulation are the prerequites of
life. Retrieved March 6, 2015, from Humber Library Database
http://search.proquest.com.rap.ocls.ca/docview/204029363?pq-origsite=summon
Chandler, T (October,2002). Oxygen Saturation Monitoring. Retrieved March 6, 2015 from
Humber Library Database. http://search.proquest.com.rap.ocls.ca/docview/218875725?pqorigsite=sumon
Chow,Wendy (2015). Prioritization. Lecture given in class in Nurs252 (466)
Potter, P., Perry,A. (2014). Canadian Fundamentals of Nursing. [5th edition]. Elsevier Canada
Roger, K., McCutcheon,K. ( September,2013). Understanding arterial blood gasses. Retrieved
from March 10, 2015, from Humber Library Database
http://search.proquest.com.rap.ocls.ca/docview/1446435771?pq-origsite=summon
Silvetre (2008) Prioritization. Lecture given in Class in Nursing252 (466)
Ward,D. and Karan,S.(2002). Effects of pain and arousal on the control of breathing. Journal of
Anesthesia. Retrieved on March 15, 2015. from Humber LibraryDatabase.
http://web.a.ebscohost.com.rap.ocls.ca/ehost/pdfviewer/pdfviewer?sid=2229cf83-0aa3-41a18d27-ff39f92f703d%40sessionmgr4005&vid=1&hid=4207

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