PA30327 lectures Flashcards Preview

Year 3 Sem 2 COPY COPY COPY > PA30327 lectures > Flashcards

Flashcards in PA30327 lectures Deck (72)
Loading flashcards...
1
Q

Define Supplementary prescribing

A
  • A voluntary prescribing partnership between an independent prescriber and a supplementary prescriber
  • To implement an agreed patient-specific clinical management plan with the patient’s agreement
2
Q

Describe who is involved in Supplementary Prescribing

A

Indepent prescriber
- doctor or dentist

Supplementary prescriber
- registered nurse, midwife, pharmacist, optometrist or allied healthcare professional

Independent and supplementary prescriber share, have access to, consult and use the same patient record

3
Q

What is included in Clinical Management Plan (CMP)?

A
  1. Name of patient
  2. Illness or conditions
  3. date on which plan is to take effect
  4. reference to class or description of medicinal product
  5. restriction/limitation as to strength or dose of meds
  6. relevant warnings
  7. arrangement for notification of
    : suspected or known ADR
4
Q

What are the disadvantages of Supplementary prescribing?

A
  • Very time consuming
  • Very prescriptive
  • Only really suitable for stepwise management of chronic conditions
5
Q

Define ‘Independent Prescribing’

A
  • prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about clinical management required including prescribing
6
Q

What should a Treatment Plan include?

A
  • Process of differential diagnosis
  • Assessment of severity of staging
  • Diagnostic tests
  • Stages of treatment
  • Medicines intended to be prescribed and evidence for this
  • How you will check for patients safety associated with this decision
  • How response to treatment will be monitored
  • Referral indicators and associated process
7
Q

what is a Compentency framework?

A
  • There are 10 competencies split into 2 domains
  1. The Consultation
    - Assess the patient
    - Consider the options
    - Reach a shared decision
    - Prescribe
    - Provide information
    - Monitor and review
  2. Prescribing Governance
    - Prescribe safely
    - Prescribe professionally
    - Improve prescribing practice
    - Prescribe as part of a team
8
Q

What are the examples of Legal frameworks?

A

Criminal law
- prove that a crime has been committed

Civil law
- prove duty of care owed to a patient has been breached (tort)

Professional body
- competence to remain registered (GPhC has statutory powers)

Employer
- vicarious liability

9
Q

Describe Human Rights Act (1998)

A
  • is relevant to health care providers since it regulates the relationship between individuals and public authorities
  • when a practitioner is making a decision about healthcare provision, it should be focused on patients’ wishes and interests
10
Q

What are the 5 underlying principles of ethical decision making?

A
  1. Beneficence
    - to do good
    - HCP should balance the benefits of treatment against risks and costs in a manner which benefits the patient
  2. Nonmaleficence
    - to do no harm
    - HCP should not harm the patient and, as all treatment has some associated harm, the harm should not be disproportional to benefits of traetment
  3. Respect for autonomy
    - self converning or independent
    - HCP should respect patient’s ability to make a reasoned and informed choice by respecting the decision-making capabilites of an autonomous individual
  4. Justice
    - being fair
    - HCP should note all patients in similar situation should be treated in similar manner, and that benefits, risks and costs should be distributed fairly
  5. Respect for the patient
11
Q

What factors might cause you to make a prescribing error?

A
  • slips of action
  • lapses of memory
  • rule-based mistakes
  • knowledge-based mistakes
  • routine
  • situational
  • exceptional
12
Q

What are the skills required for a pharmacist?

A
  • consultation skills
  • patience
  • empathy
  • shared decision making
  • evidence based medicine
  • creative thinking
  • precision
13
Q

Why is Calgary-Cambridge Guide so good?

A
  • actively determines and explores patient’s ideas, concerns and expections
  • accepts legitimacy of patient views
  • shares thinking with patient to encourage patient involvement
  • gives information in chunks
  • check patient understanding of information
  • involves patient by making suggestions, not directives
  • encourages patient to contribute their ideas, suggestions, preferences and beliefs
  • offers choices
  • negotiates a mutually acceptable plan
  • next steps, safety netting, summarsing
14
Q

Why is effective communication important?

A

More effective gathering of ALL/RIGHT information

  • revealing a hidden agenda that patient may be reluctant to share easily
  • informing a more reliable/accurate/correct diagnosis

Establishing TRUST between you and the patient

  • More likely to get the information you need
  • More efficient consultation
  • More likely to achieve a CONCORDANT outcome

More effective PROVISION of information
- patient has understanding of condition / risks and benefits of treatment / treatment

15
Q

How do we become effective communicators when talking to patients/clients?

A
  • body language
  • open Qs
  • probing questions
  • closed Qs as needed
  • identifies patient agenda/concerns
  • active listening
  • looking for verbal and non-verbal cues
  • rapport
  • management of environment
  • confident structure
16
Q

What are the barriers to effective communication?

A

Poor questioning technique

  • chain Qs
  • closed Qs
  • Leading/negative Qs

Listening

  • not actively listening
  • stepping on silences

Not identifying patient agenda/concerns
- poor identification of CUES/CLUES

Distractions

  • conscious of trying to get it right
  • environment
  • other cognitive pressure
17
Q

Describe therapeutic empathy

A
  • ability to identify an individual’s unique situation, to communicate that understanding back to the individual and to act on that understanding in a helpful way
18
Q

Define ‘Differential diagnosis’ and ‘Provisional diagnosis’

A

Differential diagnosis
- list of possible medical causes behind the presenting symptoms or physical findings

Provisional diagnosis
- most likely diagnosis based on symptoms, findings and information gathering but not a fully committed diagnosis

19
Q

What information do you need to get when taking full medical history?

A
  • previous surgery or hospital admission
  • medical condition
  • allergies
  • family history
  • medications
  • social history
20
Q

What are RED FLAG symptoms for Cardiovascular system?

A
  • SOB
  • Exercise tolerance
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea (PND)
  • Chest pain/Angina
  • Palpitations
  • Diziness/blackouts
  • ankle swelling
  • calf/leg pain
  • tiredness
21
Q

What are RED FLAG symptoms for Respiratory?

A
  • SOB
  • Exercise tolerance
  • Wheeze
  • Chest pain
  • Cough
  • Phlegm
  • Haemoptysis
  • Stridor
  • Hoarse voice
22
Q

What are RED FLAG symptoms for GI?

A
  • Weight loss or gain
  • Appetite
  • Indigestion/heartburn
  • Dysphagia
  • N & V
  • Hematemesis
  • Abdominal pain
  • Jaundice
  • Swellings
  • Change in bowel habit
  • Description of stool
23
Q

What are RED FLAG symptom for CNS?

A
  • Headaches
  • Fits/faints/loss of consciousness
  • Dizziness
  • Vision-acuity
  • Hearing
  • Weakness
  • Numbness/tingling
  • Loss of memory/personality change
  • Anxiety/Depression
24
Q

Describe the following pain assessment tool

SOCRATES

A
S - Site
O - Onset
C - Character
R - Radiation
A - Associations
T - Time course
E - Exacerbation/relieving
S - Severity
25
Q

Why is taking accurate medical history important?

A
  • Helps build the therapeutic relationship
  • Determines how the illness may have affected the patient and their family
  • Explores the patients ideas, concern and expectations
  • Eliminates serious problems
  • Determines more accurately what is wrong with the patient
  • Finds a solution
26
Q

When is Decision Aids used?

A
  • Sometimes it can be difficult for patients to make a decision
  • Patients sometimes need clear, concise and unbiased information in an easy to read formate to help them reach a decision

for example, smiley faces

27
Q

What are definitions for the following terms?

  • Decision Making
  • Reasoning
  • Judgement
A

Decision making

  • cognitive process resulting in the selection of a belief or course of action.
  • The act of choosing between two or more courses of action

Reasoning
- process of forming conclusions

Judgement
- ability to make considered decisions or come to sensible conclusions

28
Q

What are the 9 GPhC Standards for Pharmacy professionals?

A
  1. Provide person-centred care
  2. work in partnership with others
  3. communicate effectively
  4. maintain, develop and use their professional knowledge and skills
  5. use professional judgement
  6. behave in a professional manner
  7. respect and maintain the person’s confidentiality and privacy
  8. speak up when they have concerns or when thngs go wrong
  9. demonstrate leadership
29
Q

What is Berwick Report?

A
  • place quality of patient care, especially patient safety, above all other aims
  • engage, empower, and hear patients and carers at all times
30
Q

Describe Selective and Creative clinical decision making

A

Selective

  • options already exist and we use a structured process
  • decision involves selecting from a choice
  • a cognitive process

Creative

  • allowed to think more freely
  • need to generate solutions from the information gained
  • can induce emotion and bias
  • can be more risky
31
Q

What are the common stated reasons for wrong diagnosis?

A
  • too much hurry
  • not listening enough to patient’s story
  • too much attention to one finding
  • didnt reassess the situation when things didnt fit
  • overly influenced by similar case
32
Q

Reasons for wrong decisions?

A
  • made in haste
  • made without consultation
  • over-analysed
  • based on past experiences rather than new situations
  • based on other people’s decisions
33
Q

Describe the Wingfield’s 4 stage approach to decision making

A
  • gather relevant facts
  • priorities and ascribe values
  • generate options
  • choose an option
34
Q

Describe O’Neill’s 6 stage approach to decision making

A
  • gather all relevant information
  • identify and clarify the ethical problem
  • analyse the problem by considering the various ethical theories and approaches
  • explore the range of options or possible solutions
  • make a decision
  • implement and then reflect on decision
35
Q

What are the core skills of clinical decision making?

A
  • pattern recognition
  • critical thinking
  • communication skills
  • evidence based medicine
  • team work
  • sharing
  • reflection
36
Q

Define ‘Leadership’

A

the art of motivating a group of people to act towards achieving a common goal.

37
Q

What are the benefits of leadership in Pharmacy?

A

Individual level
- encourages self-reflection, identifies areas for further development, aids career progression

Local level
- enhances the effectiveness of a team, builds multi-disciplinary team working and improves the services/process being delivered

National level
- drives change and improvement across healthcare and organisations, ensures the profession takes a consistent approach to leadership development that is alinged with other HCP and strengthens the profession’s reputation and standing

38
Q

What is Monitoring regarding prescribing?

A
  • periodic measurement that guides the management of a chronic or recurrent condition
  • establishing benefit for patients is important
  • Monitoring can refer to blood monitoring, condition monitoring or patient monitoring which can be used to ensure patient safety
39
Q

Why is monitoring required?

A
  • increase in patient safety and reduction in avoidable hospital admissions
  • improvement of adherence
  • better selection of treatments based on individual response
  • better titration of treatment
  • patients’ learning about non-treatment factors that alter condition’s control
40
Q

Monitoring must be balanced against the downsides of monitoring such as…

A
  • inconvenience and costs

- the impact of false positive and false negative results which that can lead to inappropriate or delayed actions

41
Q

What are the key biochemistry tests (for monitoring) for a generalist pharmacist?

A

Blood tests monitoring

  • FBC
  • U&Es, in elderies calculate CrCl
  • Creatinine and urea
  • Lipids
  • TFTs (Thyroid function test)
  • LFTs (Liver function test)
  • Creatinine kinase
  • HbA1c
  • ACR
42
Q

What are the physical examinations that pharmacist independent prescriber is expected to be competent at?

A
  • Manual/electronic blood pressure
  • Pulse
  • Respiratory examination
  • Blood glucose
  • Urinalysis
  • BMI
  • Peak flow
  • Temperature
43
Q

What is monitoring requirements for Ramipril (ACEi)

A

BNF
- For all ACEi, renal function and electrolytes should be checked before starting (or increasing dose) and monitored during treatment

SPC

  • Renal function should be assessed before and during treatment and dose adjusted especially in initial weeks of treatment
  • Hyperkalaemia
  • Hyponatremia
  • Neutropenia
  • Cough
44
Q

What is Frailty?

A
  • a state associated with low energy, slow walking speed, poor strength
  • Common (30% of those over 80yrs old)
  • Progressive (5-15 yrs)
  • Episodic deteriorations
  • Preventable components
  • Potential to impact on QoL
  • Expensive
45
Q

What are the examples of Assessment Tools for identifying Frailty?

A
  • Gait speed <0.8m/s
  • Timed-up-and-go test <12s
  • Grip strength
  • PRISMA 7 questionnaire
  • Clinical frailty scale
  • Edmonton frail scale
  • Clinical frailty scale
  • Reported Edmonton frail scale
  • ISAR tool
46
Q

Describe PRISMA 7 Questions

A
  • seven-item, self- completion questiionaire
  1. Are you more than 85yrs old?
  2. Male?
  3. In general do you have any health problems that require you to limit your activities?
  4. Do you need someone to help you on a regular basis?
  5. In general do you have any health problems that require you to stay at home?
  6. In case of need, can you count on someone close to you?
  7. Do you regularly use a stick, walker or wheelchair to get about?
47
Q

READ (STATISTICS)

about frailty

A

For severe frailty average practice list per GP

  • 7% of population over 65 yrs are likely to be severely frail
  • In average practice this is about 27 patients per GP
48
Q

Is frailty amenalbe to prevention and treatment? if so how?

A

Yes
- healthy ageing reduces risk of fdeveloping frailty

  • Good nutrition
  • Not too much alcohol
  • Staying physically active
  • Remaining engaged in local community / avoiding loneliness
  • Patients can be signposted to NHS England and Age UK publications
49
Q

Define Multi-morbidity and Co-morbidities

A

Multi-morbidity
- multiple long-term conditions

Co-morbidities

  • when two disorders or illness occur in the same person, simultaneously or sequentially, they are described as comorbid.
  • Comorbidity also implies interactions between illness that affect the course and prognosis of both
50
Q

What is Multi-morbidity?

A

Presence of two or more long term health conditions, which can include

  • physical and mental health pathologies
  • ongoing conditions such as learning disability
  • symptom complexes such as frailty or chronic pain
  • sensory impairment such as sight or hearing loss
  • alcohol and substance misuse
51
Q

How is Multi-morbidities managed?

A
  • Care for people with multi-morbidity is complicated because different conditions and their treatments often interact in complex ways
  • Despite this, the delivery of care for people with multiple long term conditions is still often built around the individual conditions, rather than person as a whole
  • Offer care that is tailored to the person’s personal goals and priorities and seeks to address the complexities surrounding the person’s multiple conditions and treatments
52
Q

What are the tests needed prior to starting treatment of ACEi and ARB?

A
  • U&E and eGFR

- in patinets with CKD, measure serum potassium and eGFR

53
Q

What are the monitoring required until patient is stabilised on ACEi and ARB?

A

Heart failure
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation

CKD
- measure serum urea, creatinine and electrolytes 1-2 weeks after initiation

54
Q

What are the Ongoing Monitorings needed for ACEi and ARB?

A

Heart failure
- measure serum urea, creatinine and electrolytes every 3 months

Post-MI
- measure renal function, electrolytes and BP at least annually

55
Q

What is Malnutrition?

A
  • state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shpae, size and composition) and function and clinical outcome
56
Q

What is Cachexia?

A
  • a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment
57
Q

What is Sarcopenia?

A
  • age-related reduction in skeletal muscle mass in the elderly which is a natural part of aging process
  • primary Sarcopenia has no specific etiologic cause that can be identified
  • secondary Sarcopenia is where the natural process is aggravated by an extrinsic factor, such as lack of physical activity, malnutrition, chronic inflammation and comorbidity.
  • diagnosed by looking at muscle mass, muscle strength and physical performance
58
Q

Who is at risk of malnutrition?

A
  • Older people over the age of 65, particularly if they are living in a care home or nursing home or have been admitted to hospital
  • Individuals with complex health needs
    : e.g learning difficulties, mental health disorders
  • People with long-term conditions, such as diabetes, kidney disease, chronic lung disease
  • People with chronic progressive conditions
    : e.g dementia or cancer
  • People who abuse drugs or alcohols
59
Q
What is prevalence of Malnutrition in...
- Home
- Sheltered housing
- Hospital
- Care homes
?
A

Home

  • BMI <20kg/m2 = 5%
  • BMI <18.5kg/m2 = 1.8%
  • Elderly 14%

Sheltered Housing
- 10-14% of tenants

Hospital
- 25-34% of admissions

Care homes
- 30-42% of

60
Q

What are the causes of Malnutrition?

  • Physiological
  • Psychological
  • Social
  • Increased nutritional needs
  • Nutrient losses
A

Physiological

  • swallowing problem
  • taste changes
  • poor dentition
  • dry mouth
  • pain
  • constipation
  • medicine side effects
  • impaired GI function
  • hunger / thirst
  • impaired

Psychological

  • low mood / depression
  • dementia
  • loss of interest in food
  • poor appetite

Social

  • Living / eating
  • alone
  • little money
  • bereavement
  • difficulty shopping or cooking
  • reliance on others

Increased nutritional needs due to

  • infection
  • inflammation
  • pyrexia (raised body temp)
  • healing wounds
  • involuntary movements
  • increased physical activity

Nutrient losses

  • malabsorption
  • diarrhoea
  • vomiting
  • wound exudates
61
Q

What are the consequences of malnutrition?

  • Physiological
  • Psychological
  • Outcomes
A

Physiological

  • reduced fat and muscle
  • poor wound healing
  • reduced mobility, weakness, fatigue
  • increased risk of infection
  • weak cough
  • poor absorption of nutrients
  • more side effects from medicines

Psychological

  • Low mood / depression
  • confusion
  • appetite further reduced

Outcomes

  • more falls and pressure ulcers
  • more hospital admissions
  • more GP visits
  • require more prescriptions
  • longer length of stay
  • reduced quality of life
  • increased mortality
62
Q

What is the Cost of Malnutrition in UK and statistics regarding gp visit and hospital stay

A

3 million adults in UK malnourished costing 19 billion pound

3rd highest potential to deliver cost savings to NHS

Greater use of healthcare and costs associated with malnutrition mean

  • 65% more GP visits
  • 82% more hospital admissions
  • 30% longer hospital stay
63
Q

How do we measure disease related malnutrition?

A
  • BMI of less than 18.5kg/m2
  • Unintentional weight loss greater than 10% within the last 3-6 months
  • BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within last 3-6 months
  • Eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for next 5 days or longer
  • Have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
64
Q

What are the 5 steps of treating malnutrition?

A
  1. Managing factors affecting food intake
  2. Set treatment aims
  3. Food first
  4. Oral nutritional supplements
  5. Review + Monitor
65
Q

Explain the following step of Treating malnutrition

- 1. Manage factors affecting food intake

A
  • If concerns regarding swallow, has patient been referred to Speech & Language therapy?
  • If difficulty using cutlery, has patient been referred to Occupational Therapy?
  • If patient is constipated, have laxatives been prescribed?
  • Are there medications causing problems that potentially could be stopped/rationalised e.g iron causing constipation
  • If patient has nausea & vomiting, is something being prescribed for this?
  • Does the patient struggle to buy/cook food? Do they need more support or meals from Wilshire Farm Foods?
66
Q

Explain the following step of Treating malnutrition

- 2. Set Treatment Aims

A
  • Avoiding further weight loss
  • Achieving a BMI of 18.5 or 20kg/m2
  • Would healing
  • Regaining lost weight
67
Q

Explain the following step of Treating malnutrition

- 3. Food First

A
  • Improving an individuals nutritional intake with nourishing foods and drinks

Some ideas to help improve their nutritional intake include

  • older ppl need a more nutrient dense range of foods
  • nourishing meal, snack or drink every 2-3 hrs
  • appetiser (fresh air, light exercise)
  • full fat or high energy food options
  • fortify food and drinks
  • allow favourite foods at anytime of day
  • make the most of times when appetite is better
68
Q

What are the advantages of Oral Nutritional supplements?

A
  • significantly reduce mortality
  • significantly reduce complications
  • significantly improve weight
  • functional benefits
  • better energy and protein intakes in supplemented patients in all trials
  • acceptable to patients
69
Q

When is Orarl Nutritional Supplements (ONS) given?

A
  • considered for resisdents with a MUST score of 2 or more (high risk) if weight has decreased after one month of FOOD first advice
  • ASK GP to prescribe, try 2 weeks and check acceptability
70
Q

What are the Advisory Committee on Borderline substances (ACBS) approved categories for prescribing nutritional supplements?

A
  • Short Bowel syndrome
  • Dysphagia
  • Interactable malabsorption
  • Pre-operative preparation of undernourished patients
  • Inflammatory bowel disease
  • Total gastrectomy
  • Bowel fistulae
  • Disease related malnutrition
71
Q

Explain the following step of Treating malnutrition

- 5. Review & Monitor

A
  • has a weight been recorded on initiation & repeated a minimum of 3 monthly?
  • Is there an ACBS indication documented?
  • Do they have a MUST score, if so what is it?
  • Has food first advice been given?
  • Has an aim of treatment been set?
  • Which supplements are being prescribed?
72
Q

Summary - Nutrition READ

A

Malnutrition in vulnerable and elderly frail population groups is widespread.

Recognition and treatment of malnutrition in these particular groups is paramount to overcoming the negative impact on individuals health and prognosis as well as its burden on the health service.

A step-wise approach to its treatment i.e using MUST score system, adopting food first where risk of malnutrition is identified, and only then prescribing ONS is key to clinical and cost-effective treatment