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Hello friends. In this PPT I am talking about AETCOM (Attitude, Ethics and Communication module) of Pharmacology. If you like it, please do let me know in the comments section. A single word of appreciation from you will encourage me to make more of such videos. Thanks. Enjoy and welcome to the beautiful world of pharmacology where pharmacology comes to life. This video is intended for MBBS, BDS, paramedical and any person who wishes to have a basic understanding of the subject in the simplest way
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Presented at Kansas City University of Osteopathic Medicine 10/27/15 in Lecture Series in Bioethics. See live presentation here: https://www.youtube.com/watch?v=Dr3g3PeVKeo
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1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
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Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
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This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
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Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
3. Objectives
• Describe the role of palliative care in patients
with serious illness
• Understand the use of communication tools in
physician-patient interactions
• Discuss assessment and management of actively
dying patients
4. UMMC Palliative and Supportive Care
“We are a specialized team that is patient
centered and relationship based who care for
persons with advanced, serious illness. Our goals
are to help them make wise choices, focus on what
is most important to them, and provide relief from
suffering.”
UMMC Care and Communication Team
Patient Centered and Relationship Based
5.
6. “Where is the knowledge we have lost
in the information,
And, where is the wisdom we have
lost in the knowledge?”
T. S. Eliot
7. Case One
You are asked to see a 64 y/o man with
recently diagnosed small cell carcinoma of the
lung. He is experiencing pain and dyspnea and will
begin radiation therapy followed by chemotherapy
in the next few days. He has limited disease and
his oncologist is optimistic about a positive
response.
You begin opioids for symptom management
and schedule another visit in one month.
9. Palliative Care
• Palliare- “to cloak, deceive, or cover”
• Palliate- “to lessen or mitigate without curing”
• Palliative Care- term first coined in 1974 by Dr.
Balfour Mount
10. Palliative Care
• Provides relief from pain and other symptoms
• Affirms life and regards dying as a normal
process
• Intends neither to hasten death nor postpone
death
• Integrates the psychological and spiritual
aspects of patient care
11. Palliative Care
• Offers a support system to families, including
bereavement
• Uses a team approach
• Enhances quality of life and at times may
positively influence the course of a disease
• Is applicable early in the course of an illness and
in conjunction with other life prolonging
therapies
• Hospice is one facet of palliative care
12. Integrating Palliative Care into Chronic
Life-Limiting Disease Management
“best care possible”
Bereavement
Death
Terminal phase
Time
%
clinical
efforts
100
0
14. Hospice
• Support and care for patients and families in the
last phase of an incurable illness
• Attempt for patients to live as fully and
comfortably as possibly
• Focus on quality of life and symptom
management
• Continue to care for the patient, with a shift in
focus
15. Hospice
• Medicare benefit, enacted 1983
• Hospice is paid a per diem
• Pays for nursing care, meds, DME
• No routine office visits
• Hospice is a conversation and a philosophy
• Hospice is a disposition only after the
conversation
16. Hospice
• Interdisciplinary approach-nurse driven
• 24 hour on call RN
• Supplies, equipment, most medications are paid
for
• Hospice takes over medical care
• Respite care
• Do not have to be DNR
17. Hospice
• Most care provided in home
• May be provided in NH or residential hospice
• Two physicians must certify that survival is
anticipated if the disease trajectory continues
it’s expected course
• Patients may stay in hospice more than six
months
18. Hospice GIP
• Care in an inpatient setting for pain or other
symptom management
• Cannot be managed in other settings
• Intended to be a short term intervention
• Hospice makes determination of eligibility
• It is not an “automatic” level of care for
imminently dying patients
• Examples are pain crisis on IV meds and delirium
with behavioral issue
• Cap on these for each hospice
19. Early Integration of Palliative Care in
Patients with Serious Illness
• Palliative Care is not just for patients at the end
of life
• The goal of palliative care is to improve quality
of life throughout the trajectory of a serious
illness
• Focus is on symptom management, advance care
planning, psychosocial support, and relief of
suffering
20. Early Integration of Palliative Care….
• A recent study in patients with advanced lung
cancer and early palliative care revealed
improvement in quality of life and survival
• Palliative Care can be provided with concurrent
target-directed therapy
• American Society of Clinical Oncology
recommends palliative care be integrated early
in cancer patients
21. Early Integration of Palliative Care
• Generally focus on symptom management
initially
• Patients want to have relief of symptoms and
know you care- this helps build trust
• Advance Care Planning (ACP) can come later
• ACP is a conversation about the right medical
treatment for your patient
22. Early Integration of Palliative
Care….ACP
• Improves patient compliance
• Reduces hospitalizations at the end of life
• Leads to greater patient satisfaction
• Is longitudinal, iterative, incremental, and
almost always changes over time
• Slow is sometimes best-patients can only
assimilate so much information
23. Take Home Message
Palliative Care is appropriate for patients
with serious illness at any stage of their disease
process
24. Case Two
A 72 y/o woman is admitted to the CVICU
after sudden cardiac arrest. She has severe anoxic
brain injury with status myoclonus and minimal
brain stem reflexes present.
Palliative Care is consulted for goals of care.
Family doesn’t “get it” and insists on “doing
everything”.
25. Goals of Care
• A common reason for Palliative Care
consultation
• Often elderly patients with multiple medical
problems and large symptom burden
• Not just at end of life
26. Goals of Care…..
• Complex interaction requiring an intricate
knowledge of the clinical realities as well as
prognosis
• Necessitates understanding your patient’s
values, preferences, and priorities
• Skill at responding to emotion, breaking bad
news, and using a shared decision making model
27. Goals of Care-How to Conduct the
Discussion
• Through compassionate listening, establish a
bond by making a non-medical connection
• Have your patient share their narrative-this can
be both diagnostic and healing
• Understand their perception of their medical
condition (Ask-Tell-Ask)
• Ask about the “Big Picture”
• Give small pieces of information and check in
28. Goals of Care Guide
• If your health worsens, what are your most
important goals?
• What are your biggest fears and worries about
the future of your health?
• What abilities are so critical to your life that you
can’t imagine living without them?
• If you become more ill, how much are you
willing to go through for the possibility of
gaining more time?
30. Relationships- PEARLS
• Partnership- “We are going to work on this
together”, “I will be here for you”
• Empathy- “You appear sad”, “I wish things were
different”, “I imagine this is very hard”, “Tell
me more”
….silence….head nodding….emotive vs.
cognitive….never respond to an
emotion with a fact…..state the
obvious…..
31. Communication…PEARLS
• Acknowledge/Apologize- “You have done a
wonderful job caring for your mother”, “ I am
sorry I am running late and made you wait”
• Respect- “We may disagree, but I respect what
you are telling me”, “I can’t tell you how great
it is to see you doing some exercise, that’s really
important”
32. Communication PEARLS…
• Legitimize- “Anyone in your situation would be
tearful”, “It is normal to have the frustrations
you are experiencing now”
• Support- “ I am going to call your doctor so she
knows we are all working together on this”,
“Here is my contact information. I am here to
work with you.”
33. Communication…Helpful Phrases
• “Before we talk about your medical issues, tell
me a little about yourself”
• “How do you understand the big picture of your
health right now?”
• “What are your expectations of the time we
have together today?”
• “What else?”
• “Is there anything we haven’t talked about that I
should know to help care for you?”
34. Communication….Helpful Phrases
• “I think I am beginning to understand what is
bothering you”
• “Go on”
• “Uh huh” with head nodding
• “So what I heard is…”
• “Let me be sure I got this right”
• “I share your sorrow. I consider your father a
good friend.”
• “Just so we are on the same page…”
36. Take Home Message
• Goals of Care conversation requires knowing
your patient, listening to their story, and
understanding their values and preferences
• Showing empathy and responding to emotion are
essential features of communication
• Using a shared decision making model, making a
recommendation when appropriate is beneficial
37. Case Three
A 28 y/o man is admitted with pain,
dyspnea, nausea, and altered mental status. He
was diagnosed 3 years ago with melanoma and now
has widely metastatic disease including brain
mets. No further disease specific therapy is
warranted. He has spent most of the past 6 weeks
in bed and for the past 5 days has experienced the
aforementioned symptoms. His family can no
longer care for him at home. You are consulted for
symptom management.
38. Care at the End of Life
• Being present at the bedside of a dying patient
is one of the most meaningful acts a physician
can perform
• Sit on the bed, touch your patient, express
kindness both verbally and non-verbally
• Listen to what is said….and not said
• Talk about the end of life, dying, and what they
can expect
39. End of Life…What Patients Want
• Be as comfortable as possible
• Be free of pain, dyspnea, and anxiety
• Be clean
• Know what to expect
• Have someone who will listen
• Maintain dignity
• Say goodbye
• Deal with unreconciled issues
40. End of Life…What Patients Want
• Trust their physicians and nurses
• Physical touch
• Share time with friends and family
• Say “I love you”
• Say “I am sorry”
• Be sure their family is prepared
• Little things matter
41. End of Life…Assessment and
Management
• Pain
• Dyspnea
• Nausea
• Delirium
• Secretions
• Agitation
• Anxiety/Depression
• Existential Distress/Anticipatory Grief
42. End of Life…Assessment and
Management
• Grimacing
• Tachypnea
• Work of Breathing
• Delirium
• Death Rattle
• Mottling
• Pulses
• Body temperature
44. Take Home Message
• Patients and families have expectations we
should meet and they deserve
• Be present
• Prepare the patient and family
• Aggressively assess and manage symptoms
45. Objectives
• Describe the role of palliative care in patients
with serious illness
• Understand the use of communication tools in
patient-physician interactions
• Discuss assessment and management of actively
dying patients
46.
47. Advance Directives
• Legal documents that give direction to a
patient’s care when they are unable to make
their own decisions
• Apply only when they have lost decision making
capacity
• Surrogate decision maker- durable healthcare
power of attorney
• Preferences for future care- living will
48. Objectives
• Describe Palliative Care and how it differs from
hospice
• Identify goals of care and how they can help
with shared decision making
• Define some communication techniques to help
with goals of care and breaking bad news
49. Objectives
• Describe Palliative Care and how if differs from
hospice
• Identify goals of care and how they can help
with shared decision making
• Define some communication techniques to help
with goals of care discussions and breaking bad
news