CEs FROM 2012 APPROVED FOR THIS YEAR Archives

When it comes to mental health,

 what’s normal?

Mental Health Overview for Care Providers.

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 4- Approximate time required: 240 min. 

Educational Goal: 

To give a basic overview of the most common Mental Health Issues for Care givers.

Educational Objectives:          

1. Understand the difficulties in mental health issues.

2. Explain the Basics of Mental health

3. Provide a description of the 10 most common mental illnesses

4. Provide some care giver tips for caring for mental health patients

Procedure:             

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

 Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

When it comes to mental health, what’s normal?

Mental Health Overview for Care Providers

 

     When it comes to mental health, who is normal and who is crazy?  That is a hard question to answer. Aren’t we all a bit off center in some way? Despite our differences, we can, for the most part, fit into society and function well.  Unfortunately, there are those who are so far off center that they have difficulty functioning and need help fitting in.  Some of these individuals cannot even live by themselves and wind up in your care homes. Caregivers to these needy people would be wise to have at least a basic understanding of what their clients face. Hopefully by the end of this lesson, you will have a better understanding of some of the most common of society’s mental health problems.

Basic Understanding

What is Mental Health?

     As care providers you are totally involved in the physical health of your patients. You watch their hygiene, give them their medicine, control their diet, fight off any physical illnesses that crop up, make sure they get enough of what they need, etc. Most of you have got a pretty good handle on your patients’ physical health. But what about their mental health?  You may not be used to thinking in such terms.  What is mental health? “Mental health is how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others and make choices.” National Institutes of Health, Medline Plus.  When a body doesn’t function normally, we say it is in poor health. When a mind doesn’t function normally, we say that person has a mental illness.

The Difficulty in Diagnosing Mental Illness

     Our mind is one of our most complex structures, with millions of brain cells with trillions of connections to each other.  Those connections can be affected by the way we were born (congenital), environmental assaults (alcohol, drugs, toxins), and outside stresses (emotional abuse, traumatic events, overwhelming stressors) or chemical imbalances. If there are enough changes in our brain cells we begin to think and act abnormally. If the abnormality starts to interfere with normal functioning it is said to be a mental illness. Of course it is not that simple. There is almost limitless variety in brain cell connection structures from one person to another.   In addition the specifics of most mental illness can’t be seen or seen only intermittently. It’s easy to see measle spots but can you tell the difference between having a tired down day and major depression disorders? Add to all the above the fact that the mental health patient themselves are probably unaware that there is a mental health issue. They have learned to compensate for their difficulties, thus hiding the true nature of what is going on. These and other factors make mental illness one of the most challenging areas of concern in health care today.

History of Mental Health Care

     It seems to be in society’s nature to try to force its members to comply to a set standard of behaviors so everyone gets along with each other.  If a member of that society does not comply with its expectations, it has a tendency to push them out of the way until that person decides to come into compliance with normal societal behaviors.  It seems a logical way of handling aberrant behaviors. Unfortunately, logic breaks down when that person has difficulty or cannot change their behaviors. It has been a sad fact for most of human history that mental health patients have been looked down upon, shunned, mistreated, institutionalized, and even punished because of their abnormal behavior. 

     In ancient times, mental illness was viewed as spiritual in nature and the afflicted person was thought to be possessed by demons. Treatments involved trying to exorcise the evil spirit or punish the patient to purge the evil spirit. In medieval to colonial times, doctors tried to balance the humors of the body and mind by bloodletting, burning, or whipping the patient.  In post-colonial Darwinian times, mental illness was view as uncontrolled, animalistic behaviors. Treatments involved imprisonment in asylums and restraints until the person got their inner animal under control.   As modern medicine started to evolve, doctors tried to find purely physical causes for mental illness. Treatments involved extremes like electric shock therapy and lobotomy (cutting away parts of the brain).

     This seems barbaric to us now, but doctors simply did the best they could with the limited knowledge they had at the time.  Even now most individuals have very little understanding of what mental illness is and shun those who suffer, expecting them to behave themselves in public. Unfortunately, it is a normal human reaction to avoid things we find disturbing.  As caregivers, you are hampered by these same human prejudices and lack of knowledge. You may need to change your reactions to mental illness.  By educating yourselves about mental illness, you can fight against these tendencies and become better caregivers to those who need your care.  

 

What really is Mental Illness?

     Medical science has been trying to answer that question for a long time.  The answer keeps changing as our understanding improves. Shortly after World War II, the U.S. Army tried to standardize the classification of mental diseases. That first attempt has morphed over the years into to the American Psychiatric Association’s DMS IV (Diagnostic and Statistical Manual of Mental Disorders 4th edition). In 2013, they plan to update it to DMS 5.

     In the U.S., the DMS IV is now the generally accepted authority concerning mental health issues. In the DMS IV, there are more than 300 recognized types of mental disorders. There is still considerable debate whether this is the most accurate or appropriate approach to mental illness.  It is argued that there is still considerable social bias involved that clouds effective therapy. But, for the foreseeable future, it will be the gold standard in mental health issues.

 

How is DSM IV Used?

     Unlike other medical diagnosis systems, mental illness has a multitude of contributing factors that affect the patient’s mental illness. The DSM IV system tries to address all of the contributing factors to the problem. It uses a multiaxial (multidimensional) approach, assessing five different dimensions of a mental illness.

Axis I- Clinical Syndromes

This refers to the primary mental issue, similar to a regular diagnosis, for example,  Bipolar, Major Depression, Panic Disorders.

Axis II- Development Disorders and Personality Disorders

This lists any personality disorder that may be shaping the way the patient is responding to the Axis I issue, for example, Mental Retardation, Paranoia, Antisocial Disorders.

Axis III -Physical Condition

This refers to contributing physical conditions that can affect the Axis 1 diagnosis, for example brain injury, HIV/AIDS, severe Asthma, Cancer.

Axis IV –Psychosocial Stressors

This refers to outside stresses the patient has had or is now experiencing. for example,  death of a loved one, unemployment, divorce.

Axis V- Level of Functioning

This is numerical ranking of how well the patient is functioning despite the mental illness. It uses the Global Assessment of Functioning (GAF) scale of 100 to 0. Using GAF 100 represents no impairment with a gradual decline to GAF 1-10, in which the patient is a persistent danger to themselves or others.

 The multi-axial system of the DSM-IV tries to address "the whole person." It is designed to help the mental health professional intervene successfully in an emotional or psychiatric disorder by considering all conditions that affect the patient’s mental health. 

By now you might be thinking, “Why did he write such a lengthy introduction? Just tell us about the disorders already”. What I am trying to convey is there is no clear cut definitions, no easy understandings, just broad categories in which patients’ disorders might fall.  Even when a mental illness has been diagnosed, there are other matters to consider, like severity and functionality.  The only certain reality is that mental health understanding and treatment will change in the future. There will always be a need for a greater amount of patience and understanding on the part of mental health caregivers.

 

All that said and done, let’s talk about what medical science knows so far.

 

Mental Illness: The Big Picture

 

Prevalence

     Mental health issues might be more common than you think. According to an article published in the Archives of General Psychiatry, “ Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%.... CONCLUSIONS: About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life.”

     In another article, the School of Social Work- University of Washington stated, “Mental disorders are common in the United States and internationally. An estimated 26.2 % of Americans ages 18 and older – about 1 in 4 adults – experience a mental disorder in a given year…. This figure translates to 57.7 million people. “Most of these people can cope without any help, but the article continues “the main burden of illness is concentrated in a much smaller portion – about 6 %, or 1 in 17 experience a serious mental illness.” The article continued to say about half of those who suffer have two or more disorders, complicating therapy and compounding the seriousness of the issue.

 

     Mental illness is often first seen during adolescence or young adulthood, but all ages are at risk. It appears that the young and the old are particularly susceptible. The World Health Organization reported that four out the 10 leading causes of disability in the U.S. are related to mental disorders.

 

Severity

     The severity of a condition is measured by how much it interferes with normal functioning. Just as with most things in life, mental health issues are not black and white, but several shades of gray.  The severity of a condition can range from a mild inconvenience to a total debilitation of functioning and cycle back and forth. Most severe cases have two or more mental illnesses to contend with. The severity of the condition can change over time. For example, some contributing conditions can be resolved or the patient’s ability to cope can fluctuate over time. It is not uncommon for a mental illness to be a lifelong challenge. 

 

Treatments

     There has been considerable advancement in the science of mental health.  Research confirms that mental illness is a serious medical condition. Mental illness is not a result of an individual’s poor character and cannot be overcome through sheer will power and right thinking. But mental illness is not a purely physical condition, either and, cannot be cut out or drugged away.  

 

     Greater understanding has led to more effective treatments. One of the most significant advances is how medical professionals view the resolution of mental illness. We no longer try to “cure the illness.” Instead, there is a focus on the whole person and their mental functionality.  With this change of focus, between 70 and 90 percent of serious mental health patients have significant reduction of symptoms and improved quality of life. The most effective mental health therapies are a combination of pharmacological and psychosocial treatments accompanied with supports. Caregivers can play a vital role in the support system of mental health patients.

 

     The following mental health diseases are presented in no particular order. Most  were selected because you, the caregiver, requested to know more about them.

 

Mental Disorders

 

Bipolar Disorder

Description

     Bipolar disorder is a mental illness that causes extreme mood swings to be experienced by the patient. It is also known by its common name of manic depression. This is a cyclic illness characterized by a high (mania) phase and a low (depression) phase, with normal behaviors in between. Each swing through the different phases can last from weeks to months, seriously affecting the patient and those around him. Onset of the disease is often in the teens or early adulthood but can be seen in all ages. Ninety percent of suffers experience their first episode before the age of 50. It is thought to be caused by a chemical imbalance in the brain and may be an inherited tendency.

 

Symptoms

    Cycles may start with either a manic or depressive phase.

 

Mania:

     In mania, the classic symptoms are heightened mood (either euphoric or irritable), flight of ideas, pressure of speech, increased energy, decreased need for sleep, and hyperactivity. Parts of this phase can be enjoyed by the patient and those around them, especially when they are happy and get a lot accomplished. Unfortunately, the condition can also progress to the point of fragmentation of thoughts, poor decision making, risky behaviors, and even delusions. In the absence of developed speech patterns as in mental retardation or youth, symptoms can be expressed as purposeless activity

Manic episodes are often preceded by symptoms warning of an impending cycle. They can last from a few days to a few months. The symptoms are mild and often transitory with indistinct manic symptoms. At times, however, no prodromal warning signs may occur, and the episode starts quite abruptly. When this occurs, patients often wake up during the night full of energy and vigor—the so-called “manic alert.”

 

Depression

     During this “Down” phase, the patient often feels depressed, irritable, and fault finding with themselves and those around them. The patient lacks energy and thoughts become slow and sluggish. The ability to concentrate and comprehend alternatives may become impaired. Patients often feel a need for increased hours of sleep lasting from 10 to 18 hours a day. Even with the extra sleep, they still wake up exhausted. Appetite may increase. This, coupled with lack of exercise, can lead to dramatic weight gain. There are those, though, who are affected in just the opposite, with insomnia and loss of appetite. Symptoms gradually subside in each cycle. Afterward, the patient often feels guilty and is full of self-reproach for his lack of self-control.

 

Mixed-Manic

     A more rare form Bipolar episodes is called a Mixed-Manic episode. During this kind of episode the patient feels both manic and depressive symptoms either together or in very quick cycles.

 

Treatment

 

     The goal of Bipolar therapy is to balance the brain chemicals that control mood. This is often accomplished with mood stabilizers like lithium, valproic acid, and carbamazipine. Other medications can be added to control symptoms, like antipsychotics and sleeping aids. A psychiatrist made need to be consulted. Counseling can help with stress, family concerns, and relationship problems.

 

Prognosis 

 

     Bipolar disorder is a lifelong condition with time between relapses from weeks to decades. Up to 10- 20 percent of bipolar patients contemplate or commit suicide. Because of the euphoria, added accomplishments, and normal times between episodes many patients are resistant to ongoing therapy. Despite all this, the condition will not get better on its own. The patient is always at risk for another mood swing episode. Without medication, the condition will only get worse over time.

 

Major Depressive Disorder

 

Description

 

     Major depressive disorder is a clinical mood disorder that is an all-encompassing low mood. It is characterized by feelings of sadness, loss, anger, or frustration. In order for a depression to be called major depressive disorder, the episode must interfere with activities of daily living for two weeks or longer. It is different from the normal, reactive or chemically induced depression in that it appears to originate in an imbalance of chemicals or improper processes in the brain. The true cause of the disorder is still unknown but it can run in families.

 

     It is estimated that about 5 percent of the general population could be afflicted by the disorder. Depressive events are episodic in nature as shown by a gradual increase of depression symptoms that could last for months. Generally, the patient returns to normal functioning. Twice as many adult females are affected as men. 

 

Symptoms

 

     Though not all patients have them, the basic pattern to major depression symptoms are: a down mood, loss of energy, difficulty in concentrating manifesting in impaired decision making and memory loss, loss of interest in favorite activities, insomnia, and loss of appetite, though there are a minority who experience just the opposite, continual pessimism, agitation with self and others, and non-descriptive suicidal thoughts.

 

Special caregiver considerations

     There are a few symptom patterns that are of clinical significance to caregivers.

1. Patients lack the energy and focus to act on suicidal thoughts, but when they start to feel better they gain those abilities. Caregivers should be more alert to potential suicides as the patient gets better.

2. Some patients experience their worst symptoms in the morning and gradually improve throughout the day.

3. It may appear that some events triggered an episode, but in reality it was the depressive episode that caused the major event. For example, a loss of job or divorce seemed to make a person depressed but in reality they were caused when the patient started to experience the depression symptoms first.

4. In the worst cases, activities of daily living become more difficult if the patient has to make choices, for example what to wear and what to eat.

5. The loss of interest in favorites makes food taste like “cardboard,” contributing to the lack of eating.

6. The lack of movement and proper eating habits commonly lead to constipation.

7. Headaches are a common complaint.

 

Treatment

 

     Antidepressant medication is the gold standard for therapy. Psychological counseling by itself appears to be less effective. There are many antidepressant medications the doctors can choose from. Depending on how often a depressive episode occurs, the patient may have to take them for the rest of their lives. 

 

Prognosis       

 

     It is not clear what causes Major Depression and its occurrence is episodic. Depressive events can occur even in childhood. As of yet, there is no cure. Once an event occurs, the patient will always be at risk for another. Fortunately, for most sufferers, depression can be controlled. The patient can lead a normal life, though they may have to be on long-term antidepressant therapy.

 

Autism (Autism Spectrum Disorders)

 

Description

     Autism is a group of developmental disorders of the brain that affects nerve cells and how they are connected to each other. It alters the way information is processed in the brain. Those who have Autism Spectrum Disorders are characterized by impaired or underdeveloped social interactions and communication skills and are often accompanied by severely restricted interests and or repetitive behavioral issues.

 

     Autism affects each patient differently along an entire spectrum of behaviors. Each case can be mild to severe. The major types of Autism are 1. Classic or Typical Autism or just Autism, 2. Asperger Syndrome 3. Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) or Atypical Autism.

 

     The exact causes of the disorders are not well understood but start before the age of three. Science has identified some inheritable genetic factors, spontaneous gene mutations, and defects cause by certain toxins and some chemicals. It is generally accepted that autism is probably caused by a combination of factors.

 

Special caregiver considerations

At one time, it was feared that some vaccinations and poor parenting skills contributed to the risk of the disorder, but studies have proven otherwise.

 

Symptoms

 

Autism

    In typical care-home environments disruptive behaviors are usually dealt with by helping the patient alter their behaviors. Unfortunately, Autistic patients may not be able to. It is helpful to understand which behaviors are related to the disability.

According to the NIH Medline Plus website:

 “People with autism may:

  • Be overly sensitive in sight, hearing, touch, smell, or taste (for example, they may refuse to wear ‘itchy’ clothes and become distressed if they are forced to wear the clothes)
  • Have unusual distress when routines are changed
  • Perform repeated body movements
  • Show unusual attachments to objects

The symptoms may vary from moderate to severe.

Communication problems may include:

  • Cannot start or maintain a social conversation
  • Communicates with gestures instead of words
  • Develops language slowly or not at all
  • Does not adjust gaze to look at objects that others are looking at
  • Does not refer to self correctly (for example, says ‘you want water’ when the child means ‘I want water’)
  • Does not point at objects when attempting to direct others attention to objects (occurs in the first 14 months of life)
  • Repeats words or memorized passages, such as commercials
  • Uses nonsense rhyming

Social interaction:

  • Does not make friends
  • Does not play interactive games
  • Is withdrawn
  • May not respond to eye contact or smiles, or may avoid eye contact
  • May treat others as if they are objects
  • Prefers to spend time alone, rather than with others
  • Shows a lack of empathy

Response to sensory information:

  • Does not startle at loud noises
  • Has heightened or low senses of sight, hearing, touch, smell, or taste
  • May find normal noises painful and hold hands over ears
  • May withdraw from physical contact because it is over-stimulating or overwhelming
  • Rubs surfaces, mouths or licks objects
  • Seems to have a heightened or low response to pain

Play:                       

  • Doesn't imitate the actions of others
  • Prefers solitary or ritualistic play
  • Shows little pretend or imaginative play

Behaviors:

  • ‘Acts up’ with intense tantrums
  • Gets stuck on a single topic or task (perseveration)
  • Has a short attention span
  • Has very narrow interests
  • Is overactive or very passive
  • Shows aggression to others or self
  • Shows a strong need for sameness
  • Uses repetitive body movements”

source- http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm

 

Asperger’s Syndrome

     Asperger syndrome usually present with milder autistic symptoms.  Those with Asperger’s  do not have problems with intellectual disabilities but may face some social challenges and unusual behaviors or interests. Clumsiness may also be a factor. 

 

Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)
     There are those who have some but not all of the symptoms of Classic Autism and Asperger syndrome. They are placed in the category of PDD-NOS. People with PDD-NOS usually have fewer and milder symptoms that may cause only social and communication challenges.

Treatment/Prognosis

 

   As of yet, there is no medicine that alters the course of the disorder. However,  early intervention can greatly enhance a patient’s abilities.

 

Special caregiver consideration

  Because the patient has physical disabilities that affect their behaviors, it is important that caregivers carefully control the patient’s environment and make adjustment in the home as required. Expecting a patient to alter his behavior may be problematic.

 

Schizophrenia

Description

 

     Schizophrenia is a group of severe mental disorders that impairs the brain from interpreting its surroundings normally. It may result in the patient experiencing hallucinations, delusions, and disordered thoughts that result in unusual behaviors. It is the mental disease that is the closest to the classic term craziness. Left untreated, it is severely debilitating because the patient cannot perceive that anything is wrong.  Symptoms first appear most commonly between the ages of 16 to 30. 

 

Symptoms

 

   The causes of Schizophrenia are not completely understood, but there is a strong correlation with abnormal functioning of certain neurons or their associated neurotransmitter chemicals. The symptoms of Schizophrenia have been grouped into three broad categories.

Positive- Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. In other words, they are definite sign of the disease. They include hallucinations (perceiving things that no one else can- ex. hearing voices), delusions (believing ideas that are not true- ex. mind control with magnets), thought and movement disorders (disorganized patterns –ex garbled sentences or made-up words and repeating certain movement over and over again).

Negative- Negative symptoms are disruption of normal functioning, or an absence of regular behavior. They include flat affect (the person’s face does not move or they talk in a monotone voice), lack of pleasure in activities, speaking very little.

 

Special caregiver consideration

Negative symptoms lead the patient to appear lazy or sloppy. Often they need help with activities of daily living.

 

Cognitive- Cognitive symptoms are impaired mental functioning. They include reduced ability to understand information and using that information to make decisions, trouble focusing or paying attention, and reduced short-term memory.

 

Treatment

 

     Treatments for Schizophrenia focus on eliminating the symptoms of the disease not the disease itself. Treatments include antipsychotic medications and various psychosocial treatments. Positive symptoms are more responsive to medication therapy.

 

     Older first-generation drugs are called typical antipsychotics and usually are associated with more side effects. Newer second-generation drugs are called atypical antipsychotics. They generally have fewer side effects but are more expensive.   Regardless of the drug, the side effects can include drowsiness or dizziness, blurred vision, rapid heartbeat, skin rashes, and sensitivity to the sun.

 

Special caregiver consideration

1. Long-term use especially with first generation drugs can lead to tardive dyskinesia (TD). TD causes muscle movements the patient can’t control. They include facial tics, tongue rolling, tremors, and unusual walking gate. It is important for the caregiver to promptly report these side effects to the doctor. Discontinuation of the drug can lead to a recovery from TD, but sometimes the effect is permanent.  Discontinuation of an antipsychotic medicine should be done gradually.

 

 2. Treatment can sometimes be problematic because the patient does not recognize that he needs help. Those who are unwilling or unable can get long-acting depot shots of certain medications. These drugs are usually second-line therapy but certainly are a treatment option for caregivers who have difficulty treating residents.

 

Prognosis

 

     Even though Schizophrenia has been categorized as one of the most debilitating  diseases, medication and therapy can help the patient lead a normal life. Continuing research has led to a better understanding of the condition, the patients, and therapies. Because of its unpredictable nature and lack of perception on the part of the patient, therapy usually has to be lifelong. 

 

Panic Attack Disorders

 

Description

 

     "One day, without any warning or reason, I felt terrified. I was so afraid, I thought I was going to die. My heart was pounding and my head was spinning. I would get these feelings every couple of weeks. I thought I was losing my mind. The more attacks I had, the more afraid I got. I was always living in fear. I didn't know when I might have another attack. I became so afraid that I didn't want to leave my house."

     The above quote describes the anxiety disorder called panic attacks. They are episodic events that can appear without warning and last for several minutes, sometimes longer. The disorder is twice as common in women as it is in men. Symptoms usually begin before age 25, but may occur in the mid-30s.

Symptoms

 

     Panic attacks appear suddenly and usually peak in 10 to 20 minutes. Some symptoms may last longer. A diagnosis of panic attack can be made in the presence of four or more of the following symptoms: chest pain or discomfort, dizziness or faintness, fear of dying, fear of losing control or impending doom, feeling of choking, feelings of detachment, feelings of unreality, nausea or upset stomach, numbness or tingling in the hands, feet, or face, palpitations, fast heart rate, or pounding heart, sensation of shortness of breath or smothering, sweating, chills, or hot flashes.

 

Special caregiver consideration     

     Many first-time patients think they are having a heart attack and go to the emergency room for treatment. As the panic attacks increase in frequency, many patients alter their behavior that negatively affects their normal functioning.

 

Treatment

 

     Panic attack can appear without warning but some triggers can be identified and avoided. The goal of therapy is to maintain normal functioning despite the occurrence of attacks. Cognitive-behavioral therapy and medication have been reported to have the best results.  Commonly used long-term medications are SSRI antidepressants, (fluoxetine- Prozac). They may take several weeks to reach full effect. Short-term treatments are usually anti-anxiety benzodiazepines, (diazepam- Valium). Cognitive behavior therapy is a psychotherapy especially useful for treating panic disorder. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and fearful.

     If panic attacks are common, the patient should avoid alcohol and stimulants like caffeine or illegal drugs. The nicotine in cigarettes is also a strong trigger of panic attacks. These substances may trigger or worsen panic attack symptoms.

 

Prognosis

 

     Due to the unpredictable nature of the disorder, the possibility of an attack is ever present.  Fortunately, most patients respond quite well to treatment.

 

Phobias

Description

 

     Phobias are a type of anxiety disorder where there is a persistent fear of an object or a situation usually greater than the danger that actually exists. When forced to confront the fear, the patient becomes quite distressed, which can even trigger a panic attack.

 

Symptoms

 

     The patient has a fear of an item or event that is not based in reality. Since these are irrational fears, one could literally have a phobia concerning every single object and situation that exists. Here is a very abbreviated list.

 

Acrophobia- Fear of heights

Agoraphobia- Fear of open spaces or of being in crowded, public places like markets, fear of leaving a safe place

Autophobia- Fear of being alone or of oneself

Bacteriophobia- Fear of bacteria

Chiraptophobia- Fear of being touched

Enochlophobia- Fear of crowds

Gelotophobia- Fear of being laughed at

Gerascophobia- Fear of growing old

Hydrophobia- Fear of water

Iatrophobia- Fear of going to the doctor or of doctors

Lygophobia- Fear of darkness

Misophobia or Mysophobia- Fear of being contaminated with dirt or germs

Nosocomephobia- Fear of hospitals

Panophobia or Pantophobia- Fear of everything

 

Treatment

 

     Medication is of limited use. Antidepressants and short-term anti-anxiety drugs are used but by themselves cannot resolve the issue. Psychotherapy is the first-line therapy with either cognitive behavioral therapy or systematic desensitization therapy or both. A course of 10 to 20 visits with a therapist is typical. 

 

Prognosis

 

     If the patient is cooperative with therapy, the outlook for normal functioning is quite good.

 

Eating Disorders

Description

 

     Eating is a basic human need but it is more than just satisfying a physical desire. Strong emotional responses can be tied to the experience of eating. In some ways, it’s our way of controlling our environment or at least our reaction to what is going on around us.  Eating disorders are illnesses where there is a severe disturbance in thoughts and emotions that lead to out-of-control eating patterns that can cause harm.  Victims of these disorders become obsessed and distressed with food and body weight. They also can lose proper perspective about the consequences of their actions.

 

     The main types of eating disorders are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. The exact cause of these disorders is not fully understood. It is believed to be combination of genetic, biological, and environmental factors. It has been described as “Genetics loads the gun but circumstances pull the trigger.”  They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. Many sufferers can trace the onset of their disorder to a severe emotional event, like mental abuse, sexual trauma, or severe peer pressure.

     Overwhelmingly, more young women are diagnosed with these conditions than men. It is thought to be in part due to bias on the part of doctors and society. Men who have the symptoms are often diagnosed with other conditions instead of an eating disorder, such as depression or obsessive compulsive disorder.

 

Symptoms

 

Anorexia Nervosa

    Anorexia Nervosa is characterized by the patient’s extreme thinness, at least 15 percent underweight, obsessing about thinness, distorted feeling about self-esteem and body image, intense fear of gaining weight, and denial about the consequences of their eating habits.

These lead sufferers to weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia nervosa may also engage in binge-eating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas.

 

Bulimia Nervosa

     Bulimia Nervosa sufferers have frequent bouts of overeating. They feel ashamed of their behavior and binge in private. Often they feel a lack of control over these episodes and stop only when they are interrupted or become sick. These binges are followed by compensating behaviors, like vomiting, laxatives, and excessive exercise.   Unlike anorexia nervosa, people with bulimia nervosa usually maintain a normal weight, some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape.

 

Binge-Eating Disorders

      Binge Eating Disorders occur when people lose control over their eating habits, but binges are not followed by compensating behaviors. This results in obesity.

     As a group sufferers of eating disorders often report feeling powerless about their socioeconomic environment, and view eating, dieting, exercise, and purging as an  empowering means of controlling their circumstances. The consequences of these behaviors are detrimental to the health of the patient and can be life-threatening. Uncontrolled eating disorders can lead to amenorrhea, tooth erosion from stomach acid, osteoporosis, scurvy, kidney failure, electrolyte imbalance, dehydration, chronically inflamed sore throat, GERD, uncontrolled bowels, cardiac problems, brain atrophy, and suicide.  

Treatment

 

     Eating disorders are real, treatable medical illnesses. Successful therapy includes both the physical needs of the body and the emotional needs of the patient. Efforts to achieve and maintain a proper weight is just the first step. Psychotherapy can help the individual identify and address the underlying emotional problem that causes or contributes to the abnormal eating behavior.

 

Prognosis        

 

Uncontrolled eating disorders can be a serious health problem. Fortunately, therapy has been shown to be quite effective. Individual or group psychotherapy is key to recovery and relapse prevention. An important note is sufferers of eating disorders have the third highest rate for self-abuse and suicide.

 

Special caregiver consideration

     Some antidepressants like Prozac, used to treat the underlying depression and to help reduce the binge cycle, have been linked to an increased suicide risk in teens and young adults. Caregivers are cautioned to monitor their patients for thought of suicide after therapy is started.  

 

Obsessive-Compulsive Disorder (OCD)

Description

 

     Obsessive- Compulsive Disorder is an anxiety disorder where intrusive thoughts are experienced by the patient. It causes uneasiness, fear, worry, and apprehension. These thoughts are hard or impossible to control or ignore. To relieve the distress, the patient will perform rituals that temporarily reduce the anxiety the intrusive thoughts produce -obsessions. The patient is most often aware that the obsessions are not based in reality but feels compelled to act on them anyway- compulsions.

     "I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a 'bad' number."

"Getting dressed in the morning was tough, because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. I knew that was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me. I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I got treatment."

 

Symptoms

 

     Those who suffer from OCD experience thoughts or images about things like fear of germs or dirt, acts of violence, hurting themselves or loved ones, sexual acts or conflicts with religion. Typical rituals include hand washing, locking and unlocking doors, hoarding, repetitive acts, ordering, and counting. What sets these symptoms apart from normal actions is that the patient feels no pleasure when performing the rituals, only temporary anxiety relief. They feel that they must act or they experience significant distress. According to diagnostic criteria, the patient will spend at least one hour a day on these thoughts and actions.

 

Treatment

 

     A combination of psychotherapy and medication has proven to be the most effective treatment for OCD. Psychotherapy may include cognitive behavior therapy and antidepressants and tricyclic antidepressants. Clomipramine is particularly effective but side-effect management may be required.  

 

Prognosis

 

     It is unclear why OCD happens. There may be inherited aspects, physical or chemical damage, or an imbalance in neurotransmitters. Brain scans have shown that the OCD brain functions differently. Therapy has been shown to be effective at reducing symptoms so the patient can regain control of their life. Medication usually takes longer to see the effects, up to three months. Patients should be counseled that when they start to feel better, they should continue to see the medical professional regularly for at least 12 months and notify them if symptoms start to return. Fortunately patients can go on for many years before their symptoms reappear, and some may not get symptoms again.

 

Post-Traumatic Stress Disorder (PTSD)

Description

 

     Post-Traumatic Stress Disorder is an abnormal response to a stressful event and is classified as a panic disorder. When a person experiences a traumatic event, the body copes with the situation by feeling shock, anger, fear, panic, and even guilt. Over time, these feelings will naturally fade. For some, though, these feeling continue or even get stronger until they interfere with normal living. An example of this is a young World War II paratrooper who was so traumatized by the events of the D-Day invasion that he became temporarily blind. PTSD has also been called shell shock and battle fatigue.

 

Symptoms

 

     Anyone who experiences a traumatic event can develop PTSD. It depends on their genetics, coping skills, social support network, neurotransmitters, and hormonal make up.  Symptoms last at least one month and are often grouped into three categories. Reliving - flashbacks, nightmares, hallucinations, and distressed feeling around reminders of the event. Avoiding- staying clear of people places and things are reminders of the trauma. Increased arousal-  excessive emotions, problems relating to others - including feeling or showing affection, difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, and being "jumpy" or easily startled. In PTSD, these symptoms are felt to the point of impairment. The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea, and diarrhea.

 

Treatment

 

     From a medical perspective, treatment could be summed up as “medicine controls the symptoms and counseling heals.” A wide variety of mental health drugs are available to the doctor. Selection of which medicine is used depends on the predominant symptoms.

 

     Similarly, a variety of psychotherapies could also be utilized, including: Cognitive behavioral therapy- recognizing and change thought patterns that lead to troublesome emotions, feelings, and behavior Exposure therapy- reliving the traumatic experience (done in a well-controlled and safe environment). The goal is to help the person confront the fear and gradually become more comfortable with situations that are frightening the patient and causing anxiety. This has been very successful  PTSD treatment. Psychodynamic therapy- focusing on helping the person examine personal values and the emotional conflicts caused by the traumatic event. Family therapy- may be useful because the behavior of the person with PTSD can have an effect on other family members. Group therapy- may be helpful by allowing the person to share thoughts, fears, and feelings with other people who have experienced traumatic events. Eye Movement Desensitization and Reprocessing (EMDR)- is a complex form of psychotherapy that was initially designed to alleviate distress associated with traumatic memories but is now also used to treat phobias.

 

Prognosis

 

     In most cases, symptoms start to appear within three months after the traumatic event. A few do not have symptoms until years later. Depending upon severity, some people recover within six months, while others suffer much longer. Without treatment, the patient could develop other conditions, like depression, other anxiety disorders, and alcohol or substance abuse. Early recognition and treatment leads to better outcomes. Post-trauma counseling has been proven to be effective in reducing the occurrence of PTSD.

 

 

Generalized Anxiety Disorder

Description

 

     Generalized anxiety disorder (GAD) is a pattern of uncontrollable constant worry and anxiety that interferes with normal functioning over a long period of time that is not attributed to another disorder or condition (for example,  worry about phobias, about being fat- anorexia. chemical abuse, etc.). It affects twice as many women as men with onset happening from youth to old age. The median age of onset is 31. There is some evidence that the elderly may be more susceptible to GAD as indicated in the increased use of anti-anxiety drugs in this portion of the population.  Long-term, constant worry can have a negative effect on the general health of the patient.  For example, constant worry and stress reduces the immune system, leads to teeth grinding, increases blood pressure, tends to upset bowels, or leads to constipation.

 

Symptoms

 

     By definition, GAD is anxiety and worry that is associated with at least three of the following six symptoms (with at least some symptoms present for more days than not for the previous six months). Note: Only one symptom is required in diagnosis for children.

 

1. Restlessness or feeling keyed up or on edge

2. Easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

 

Treatment

 

     Unfortunately, GAD is quite hard to treat. Often the patient will go to their regular medical doctor who prescribes anti-anxiety drugs. This is no more than a short- term fix, a chemical crutch. The patient starts to rely on the medication to cope with life and becomes addicted, both chemically and behaviorally. This pattern is often seen in the elderly. Those patients who included psychotherapy in there treatments showed a marked reduction in the use of anti-anxiety drugs. Effective psychotherapy could include; relaxation-based treatments or biofeedback, cognitive therapy, relaxation training, anxiety management training, or some combination of these procedures in groups session or alone. Course of therapy can be 12 weeks with follow up every few months.

 

Prognosis

 

     As of yet there remains a need for greater understanding of what causes GAD. A patient can maintain a functional life most effectively with a combination of psychotherapy and medication, though it is more difficult if there are addiction issues to contend with.

 

Personality Disorders

Description

 

     There are those individuals who never seem to fit into regular society. They just seem “wrong-headed,” to the point where one would have to wonder how they function day to day. If you were to look closer, some of these individuals could be diagnosed with a mental illness called a Personality Disorder.

 

     Those who suffer from Personality Disorders experience rigid and inflexible thought patterns. They find it difficult to react to the changes and demands of life. This thinking and behavior can lead to significant limitations in relationships and social situations. Often they have a narrow view of life, blaming their troubles on others because they believe their way of thinking is normal.

 

Symptoms

 

     There are many types of personality disorders, each with their own signs and symptoms. The three main groupings are, Cluster A- Odd or eccentric behavior, Cluster B- Dramatic, emotional or erratic behavior, and Cluster C- Anxious, fearful behavior. 

 

An example of each are;

 

Cluster A

 Paranoid Personality Disorder. The patient interprets the actions of others as deliberately threatening or demeaning. They usually are untrusting, unforgiving, and prone to anger or have aggressive outbursts without justification. They perceive others as unfaithful, disloyal, condescending, or deceitful. They may also be frequently jealous, guarded, secretive, and scheming, and may appear to be emotionally “cold” or excessively serious.

 

Cluster B

Borderline Personality Disorder. These patients have extreme "black and white" thinking. They experience instabilities in relationships, self-image, identity, and behavior. This often leads to self-harm and impulsivity.

 

Cluster C

Avoidant Personality Disorder.  These personalities are often hypersensitive to rejection and are unwilling to become involved with others unless they are sure of being liked. They experience excessive social discomfort, timidity, and fear of criticism that leads them to avoid social or work activities that involve interpersonal contact.

 

Treatment

 

     Here again, medication helps manage symptoms and psychotherapy heals. The goals of psychotherapy are to: 1. Help the patient see the unconscious conflicts that are contributing to or causing their symptoms, 2. Help the patient  become more flexible with their behavior patterns that interfere with everyday living, and 3. Help the patient recognize the effects of their behavior on others.

 

Prognosis

 

     The more that is learned about personality disorders, the more effective therapy becomes.  There is a strong causal relationship between child abuse and neglect and the development of the disorder. Genetic and other factors may also make a person more vulnerable to these diseases.  Unfortunately, diagnosing and treating personality disorders is difficult because of the many factors involved, but a fulfilling life can be achieved with help.

 

Attention Deficit Hyperactivity Disorder (ADHD and ADD)

Description

 

     Attention Deficit Hyperactivity Disorder has been classified as a brain development disorder where portions of the brain that control the attention attributes develop at a slower rate or have incomplete development. The result is the patient has trouble remaining focused, is easily distracted, and can be impulsive and hyperactive. 

 

Symptoms

     Diagnosis can be hard because most symptoms are seen as regular activities in normal children and adults. Each person has their own unique manifestation of conditions but there are three main subgroups: Predominantly hyperactive-impulsive, Predominantly inattentive, Combined hyperactive-impulsive and inattentive. According to the DSM-IV, a diagnosis can be made if there is a manifestation of symptoms that causes a significant impairment for at least six months.

 

Those symptoms can include:

 

Inattentive- being easily distracted, missing details, forgetting things, and frequently switching from one activity to another. Difficulty maintaining focus on one task. Becoming bored with a task after only a few minutes, unless doing something enjoyable.  Difficulty focusing attention on organizing and completing a task. Difficulty learning something new or trouble completing or turning in homework assignments. Patients often lose things. They don’t seem to listen when spoken to, daydream, become easily confused, and move slowly. Difficulty processing information as quickly and accurately as others. Struggle to follow instructions.

Hyperactive- fidget and squirm in their seats. Talk nonstop.  Dash around, touching or playing with anything and everything in sight.  Trouble sitting still during dinner, school, and story time. Constantly in motion. Difficulty performing quiet tasks or activities.

Impulsivity-  very impatient. Blurting out inappropriate comments, showing their emotions without restraint, and acting without regard for consequences. Difficulty waiting for things they want or waiting their turns in games.

 

Treatment

 

The goal of therapy is not to eliminate symptoms but to reduce the impairment the patient experiences. The most effective long-term therapies are a combination of stimulant medications to increase brain level function and behavioral therapies that enable compensating coping skills. 

 

Prognosis

 

     ADHD can't be cured but it can be successfully managed. Treatments therapies are partnerships among the patient who learns coping skills, medical professionals who provides the medication and helps manage side effects, and family/caregiver/mental health professionals who provide training and behavioral support.

 

Special caregiver note

     There is some controversy in the use of addicting stimulant drugs in patients who are children. Long-term studies have shown that addiction is a risk but usually not an issue with proper management. Some studies have shown that without these medications, patients tend to develop substance abuse issues later in life as they try to cope with their impairments.

 

CAREGIVER’S ROLE

Caregiver Frustration

 

     When I owned and operated my care homes, one of the most challenging aspects of In Home Care was mental health issues. From depression to dementia, it’s just harder to deal with residents in your homes who have impaired ability to reason and think. It is frustrating when your patients don’t think and act the way you expected them to, and you can’t apply normal reasoning to them. I can remember thinking, “I can’t get them act right-no matter what I say. Now what am I going to do? I wish I could just lock them up so I don’t have to deal with them anymore.”

 

Barriers to Proper Care

 

     My frustrations led me to inappropriate thoughts. These people needed me and my caregiving abilities or they wouldn’t have been in my home in the first place. What helped me turn the corner to proper caregiving was to start to understand what was really going on in their heads and what was going on in mine.  You can “turn the corner” to proper caregiving by identifying barriers to proper care and working to remove them.

 

Patient Barriers

     Patients who suffer with mental illness are not stubborn or lazy or grouchy or have other personality flaws. It is an illness that has its roots in a medical condition. The patient has an impairment that prevents them from acting normally. 

-Impaired ability to communicate

-Impaired ability to change behaviors

-Impaired ability to understand what is going wrong in them

What may be one of the biggest barriers of all is the fear of being stereotyped as a “crazy person.” It leads the patient to avoid medical providers and be uncooperative with  therapy.

 

Caregiver Barriers:

     Caregivers have their own set of baggage that throws up barriers to proper care.

-Lack of knowledge/training

-Unrealistic expectations

-Being unprepared for the challenges of care, both mentally and physically.

Stereotyping, not seeing the patient as a person- just the stigma of “being crazy” prevents proper caregiving.

 

Mental Health Caregiver Techniques

 

     This article is not a training manual for mental health caregiving that lists all to “dos and don’ts” of in-home care. But I would like to give a few pointers that might smooth the way to proper care for your patients with mental illness issues.

 

Reflective Practices

     The “Practice” of In Home Care giving is how you apply your beliefs, abilities, and resources to meet the needs of the patient.  A “Reflective Practice” is to regularly review your past experiences –describe, analyze, evaluate- and use the information to change future practices.

 

     A few questions you might ask yourself and your staff are: What stereotyping is shown in your behavior? How unprepared is your home?  Are you professional enough to get past all the difficulties? Are you willing to learn new ways of caring? What was your internal dialog when you last approached the patient? Were you able to provide empathic, compassionate care to this individual? Did you show an unconditional positive attitude toward your patient with a mental illness?

In other words “The first barriers to care to remove are the ones you threw up yourself.”

 

Develop a Plan of Action:

     Find what works, break it down into repeatable steps, write it down in a way that can be used for training, follow the steps, and always improve.

You might find the following a useful part of your plan.

  1. Find out what the diagnosis is.
  2. Educate yourself on the illness
  3. Find out what the goals of therapy are
  4. Find out what information and observations the doctors and mental health

professionals want about the patient and develop methods for getting it to them.

  1. Collect information from family and friends about what has worked in the past.
  2. Decide what to do in advance about difficulties and dangerous circumstances that

might arise. (examples: What to do if the patient doesn’t follow therapy. How and when to place the patient in the hospital- even against their will.)

  1. Provide an orientation for the new move-ins. Include house rules, patient rights,

boundaries and expectations (both yours and theirs).

 

Compliance with Therapy:

     Treatments are partnerships between the patient, doctor, and caregiver. The best outcomes happen when all understand their part and work as a team. It is vital that early identification of symptoms and consistent follow-through is achieved.

Ideas for the Patient:

  1. Keep a journal. Keeping track of the patient’s personal life can help identify what is causing stress and what seems to make them feel better. 
  2. Be prepared for the patient’s doctor visits. Write down some notes to take with them.

Thing to write down include:

       - Symptoms experienced and how intense they were.

- Any special events that triggered the symptoms like events, dreams, and

memories.

- Any questions for the doctor.

- What causes them stress.

  1. Take a trusted family member or friend if possible with them to the doctor visits.

 

Suggestions for the Caregiver

 

     Take good caregiver notes. Patients are impaired from seeing things correctly. You can provide proper perspective to the information mental health professionals receives. You can also provide vital information, such as a list of medications and health conditions the patient has or has developed since their last visit.

 

     Be prepared for down turns and have an action plan in place.

Watch for and make note of: marked changes in personality, eating or sleeping patterns, inability to cope with problems or daily activities, strange or grandiose ideas, excessive anxiety, prolonged depression or apathy, thinking or talking about suicide, extreme mood swings or excessive anger, or violent behavior.

Always remember: Many people who have mental illness consider their symptoms a normal part of life. Patients often avoid treatment out of shame or fear. Confronting patients directly about their delusions or hallucinations rarely works because their illness prevents them from seeing them as anything but real.  

 

     Laws vary from state to state, and it can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, caregivers may have to call the police to take their patients to the hospital. Contacting the police and hospital before hand and asking about proper procedures can really make a difference in a stressful situation.  

 

Patient Advocacy

 

    With workloads going up and reimbursement rates going down, sometimes the health system breaks down and patient’s needs are forgotten. Sometimes you have to do battle for your client to get what they need. Being respectful gets more cooperation but sometimes pushing until needs are met is in the best interests of your clients and your business.

 

Care Coordinator

     The doctor and case workers may be in charge, but in my experience the best outcomes happen when the caregiver takes responsibility. Caregivers are in the best position to ensure that every needful thing is done, that proper follow up is achieved, that different types of care is coordinated, and communication happens between the different members of the healthcare team. Keeping a check list of important items in the patient’s records is very helpful.  Items to include are: immunizations, dental and eye exams, physicals, required blood and other monitoring tests, behavioral, occupational, and physical therapies.

 

Conclusion

 

     Understanding mental health and how to care for the mentally ill has been a  challenge throughout the years. For those charged with the care of mental patients, the realization that the illness is both a physical and a psychological impairment has led to more effective and humane treatments. There is more hope than ever before that those who suffer can feel well again.

 

     For those who cannot make it by themselves in normal society, the support of a Care Home can make all the difference in maintaining therapy. Caregivers who take on the challenge of providing that needed support can best do so if they are properly prepared.

 

     For caregivers in any setting (Adult Foster Care, Mental Health Homes or Developmentally Disabled), understanding the barriers to proper care and working on removing them is a very effective way to be prepared. Gaining underling knowledge can go a long way in understanding and preparing for the challenges the In Home Care provider may face.

 

 

 

References

 

1. Mental Illness and the Family: Recognizing Warning Signs and How to Cope. Mental Health America.

http://www.nmha.org/go/information/get-info/mi-and-the-family/recognizing-warning-signs-and-how-to-cope

 2. Mental health: What's normal, what's not. Mayoclinic.com.

http://www.mayoclinic.com/health/mental-health/MH00042  

3. History of  mental disorders. Wikipedia

http://en.wikipedia.org/wiki/History_of_mental_disorders               

4. Classifactions of mental disorders. Wikipedia.

http://en.wikipedia.org/wiki/Classification_of_mental_disorders            

5. Facts about the prevalence of mental illness, Mental Health Reporting. School of Social Work, University of Washington.

http://depts.washington.edu/mhreport/facts_prevalence.php

6. Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J., Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. Epub 2010 Jul 31.abstract PubMed, National Library of Medicine, National Institute of Health.

http://www.ncbi.nlm.nih.gov/pubmed/20855043       

7. Dr. Brian Burke, Abnormal Psychology, Fort Lewis College

 http://faculty.fortlewis.edu/burke_b/Abnormal/Abnormalmultiaxial.htm           

8. What is Mental Illness: Mental Illness Facts. National Alliance on Mental Health

http://www.nami.org/template.cfm?section=about_mental_illness        

9. Bipolar Disorder (DSM-IV-TR #296.0–296.89),Brown University

 http://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/Bipolar%20Disorder.pdf

10. Autism. Medline Plus, National Library of Medicine, National Institute of Health.

http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm

11. Facts about ASD, Autism Spectrum Disorders (ASDs). Center for Disease Control and Prevention

http://www.cdc.gov/ncbddd/autism/facts.html

12. Autism. Wikipedia

http://en.wikipedia.org/wiki/Autism

13. Asperger Syndrome. Wikipedia

http://en.wikipedia.org/wiki/Asperger_syndrome

14. What is Schizophrenia, Schizophrenia. National Institute of Health

http://www.nimh.nih.gov/health/publications/schizophrenia/what-is-schizophrenia.shtml

15. Schizophrenia. wikipedia

http://en.wikipedia.org/wiki/Schizophrenia

16. Schizophrenia. BehaveNet.com

www.behavenet.com/schizophrenia

17. Panic Disorder: When Fear Overwhelms. National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms/panic-disorder-when-fear-overwhelms.shtml

18. Panic Disorders, Panic Attacks PubMed Health, US National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001922/

19. Panic Disorders. Wikipedia

http://en.wikipedia.org/wiki/Panic_disorder

20. Fred Culbertson, The Phobia List. PhobiaList.com

http://phobialist.com/

21. Phobia. Wikipedia

http://en.wikipedia.org/wiki/Phobia

22. Generalized Anxiety Disorder. MayoClinic.com

http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502

23. Timothy A. Brown, Tracy A. O’Leary, David H. Barlow, Chapter 4 Generalized Anxiety Disorder.

Clinical Handbook of Psychological Disorders, Third Edition: A Step-by-Step Treatment Manual. Guilford Publication. 2001

http://commonweb.unifr.ch/artsdean/pub/gestens/f/as/files/4660/21992_121827.pdf

24. Eating Disorders. National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml

25. Eating Disorder. Wikipedia

http://en.wikipedia.org/wiki/Eating_disorder

26. Eating Disorders.Healthy Minds, Healthy Lives. American Psychiatric Association

http://healthyminds.org/Main-Topic/Eating-Disorders.aspx

27. Obsessive-Compulsive Disorder: When Unwanted Thoughts Take Over. National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/obsessive-compulsive-disorder-when-unwanted-thoughts-take-over/obsessive-compulsive-disorder-when-unwanted-thoughts-take-over.shtml

28. Obsessive-compulsive Disorder. Wikipedia

http://en.wikipedia.org/wiki/Obsessive%E2%80%93compulsive_disorder

29. Post-traumatic stress Disorder (PTSD). MayoClinic.com

http://www.mayoclinic.com/health/post-traumatic-stress-disorder/DS00246/DSECTION=treatments-and-drugs

30. Posttraumatic Stress Disorders, Anxiety and Panic Disorders. WebMD.com

http://www.webmd.com/anxiety-panic/guide/post-traumatic-stress-disorder

31. Posttraumatic Stress Disorder. Wikipedia

http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder

32. Personality Disorders. MayoClinic.com

http://www.mayoclinic.com/health/personality-disorders/DS00562

33. Personality Disorder. Wikipedia

http://en.wikipedia.org/wiki/Personality_disorder

34. Personality Disorder. Mental Health America

http://www.nmha.org/go/information/get-info/personality-disorders

35. Caring for Patients with Mental Health Disorders. RN.com. AMN HealthCare Education Service

http://www.rn.com/getpdf.php/1679.pdf?Main_Session=66bee95ae8fc069ca167b24a01091936

 

When it comes to mental health,

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Mental Health Overview for Care Providers.

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Diabetic in my Home – Now What Do I Do?

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2.5- Approximate time required: 150 min. 

Educational Goal: 

To give a basic overview of in home diabetic care.

Educational Objectives:

1. Explain the role of the care giver in diabetes care.

2. Enumerate and explain the step in diabetes.

3. Explain what and how to monitor events in diabetes care

4. List was is involved in routine care for diabetics

 Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

 Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

Diabetic in My Home – Now What Do I Do?

 

     The prevalence of diabetes in older persons is going thru the roof.  According to the Center for Disease Control, 10.9 million U.S. residents aged 65 or older have diabetes -  that’s 26 percent or 1 in every 4. Last year alone, 390,000 new cases were reported.  What that means to Adult Foster care, Developmental Disabled and Mental Health Homes is that sooner or later, you will probably have a diabetic in your home and will have to deal with it. So, let’s deal with it.

The Team Approach

     One of the first things that will impact your operations as you take care of a diabetic patient is being overwhelmed by all the things you have to know and do. There is an overwhelming amount of information on diabetes because it affects every aspect of a patient’s  health.  Diabetes is so complicated that the only good way to manage it is with a team approach.  Who’s on the team?  Doctors, nurses, podiatrists, dentists, eye doctors, dietitians, diabetic educators, social workers, pharmacists, insurance carriers - that’s who.  And now, you’re on the team.

 The Role of the In-Home Caregiver

      First. In- Home care is where the actual work is done, where the rubber meets the road, so to speak.  All those wonderful people willing to help with resources and knowledge won’t mean a thing without you, the caregiver.  There is work to do and caring to be done.  You have to see that the diabetic patient is taking care of everything that they need to do or you have to do it for them.  Bottom line, if things slide, a price will be paid later. There is no getting around it. The patient will eventually get sicker.

      Second. Somebody has to coordinate the efforts of all the team members. Usually it’s the patient who’s in charge, but now you are in charge on their behalf.

     Third. Everyone is supposed to be for the patient, but in my experience people get busy and things get in the way. It’s too bad that patients in care homes sometimes become second-rate medical concerns. It is in your business’s best interest to keep everyone on their toes.  Battle for your clients if you think any of the care team is slacking. All of the effort will be worth it because your client will live longer and require less work if they remain healthy.

The Work of Diabetes Care

     There is no “best practice” way of taking care of diabetes. There is no program that details every step to take in keeping a diabetic healthy. Every attempt to make such a program has ultimately failed because everyone is so darn unique.  It is now the prevailing medical wisdom to establish general guidelines and let the care team individualize each course of therapy and monitor for results. The care coordinator’s job is starting to sound more important, isn’t  it? 

     The Center for Disease Control and Prevention, National Institute of Health, and the National Institute of Diabetes and Digestive and Kidney Disease recommend a general four-step plan.

Step 1: Learn About Diabetes

     It’s important for you and the patient to know what is going on.  Knowing the whats, helps with the whys, which helps with the doing of diabetes care.  I recommend communicating with a diabetes educator about the subject  In brief, diabetes is a condition where the body has lost control (automatic self-regulation) of how the body produces (and sometimes stopped making) and uses insulin, which in turn affects blood glucose (blood sugar- the fuel that drives us) and blood lipids (fats like triglycerides and cholesterol ), which combined in turn affects—everything. 

     When things get out of “diabetic” whack, bad things eventually happen.  Bad things like heart attack, stroke, eye problems, nerve damage, kidney problems, gum disease, amputations, lowered immune system, and incontinency.  There is no such thing as a “slight case” of diabetes. Every case is serious and is causing now or will cause infirmity and death in the future. 

     Those who take care of the elderly might hear, “I’m old, it’s just doesn’t matter.” They just want to let things slide until they kick the bucket. But unfortunately things rarely go so smoothly.  Most commonly, letting things slide for a person of any age results in a long, drawn-out period of progressively worsening condition and suffering.  Nobody really wants a long, drawn-out period of suffering. The patient is just  overwhelmed like everyone else.  If you get one of these ‘ornery old coots who doesn’t want to change, you will have to help them change.

      Let me end this section on a more positive note. When blood glucose is kept normal, patients feel better with more energy, are less tired and thirsty, have fewer skin and bladder infections, have fewer problems with their eyes, feet and gums. Everyone wants to feel better.

Step 2 Know the Diabetes ABCs

     When the body doesn’t function automatically, you have to do things manually. In order to make the correct manual adjustments, you have to know how things are going.  That means monitoring.  The diabetic monitoring ABCs are:

     A is for A1C.  or HbA1C. Some glucose sticks to the hemoglobin molecule in the blood stream. The more glucose floating around, the more it sticks to the hemoglobin and becomes HbA1C.  Counting up the A1C shows what your blood glucose has been over the last three months. The A1C goal for many people is below 7 percent. The doctor will determine what the patient’s individual goal should be. A more day-to-day or even minute-by-minute monitoring is done by home blood glucose monitoring devices. That’s the “finger stick and put blood on a test strip” machine. They are really helpful in the day-to-day, normal living efforts of diabetics and their care givers. Finger stick readings should be recorded for future references. Up and down patterns and individual readings will help you with things like diets and determining if meds are working (or working too good) or how much to exercise.

     B is for blood pressure. The goal for most people with diabetes is below 130/80. If you have a home blood pressure machine or use one of those machines at the drug store or mall, keep in mind that blood pressure machines vary in reading all the time. At home you’re looking for long-term trends. Individual recordings are less important, unless there is a significant spike up or down. These fluctuations can be minimized if the blood pressure is taken under the same conditions every time. Keeping a long-term record of readings and sending it to the doctor will be of value. High blood pressure makes the heart work too hard, and is bad for the eyes and kidneys, too.

     C is for cholesterol. Cholesterol readings can be kind of confusing. There are several kinds blood lipids (blood fats) that all are important to keep track of. Fortunately, the doctor worries about the individual tests and readings. Your main concern is how close to the goal is the patient. For your general reference,   the LDL goal for people with diabetes is below 100. The HDL goal for men with diabetes is above 40. The HDL goal for women with diabetes is about 50. Sorry, guys, women can tolerate more fats in the blood stream than we can. LDL means Low Density Lipids and it is the bad cholesterol. Think of LDL like big fluffy cotton molecules that can easily clog up the veins and arteries. HDL means High Density Lipids or good cholesterol. These are more compact pellets that easily slip through blood vessels.

     The CDC didn’t mention it, but I would include weight in my measurements and goals. I guess the ABCWs didn’t sound too good (just joking). Seriously, though, 85 percent of type 2 diabetes patients are overweight, 54 percent are obese. That just adds to the problems later on.

Step 3 Manage your Diabetes

      This is where we roll up our sleeves and get to work. I have my own set of letters. DEHM -Diet, Exercise, Hygiene, Monitoring. Diabetes care is a marathon, not a sprint. Just keep at it. If you fall behind or stop, don’t worry, just start up again. No matter how many time you have to, keep starting up again, keep going. All your efforts do have an impact on the overall health of the patient. My number-one caregiving recommendation is to start and stick to a routine. Work at establishing patterns. They turn into habits. In-Home caregivers have the advantage of controlling the environment of the home. Bad habits are more easily broken when you take advantage of the turmoil that is caused when a person moves in and tries to adapt to the new surroundings. If routines are already in place and enforced, change will come faster. A couple of words of caution. The elderly have had a very long time to ingrain habits. Also and more importantly, they have physically lost some of the abilities to cope with change. DD and mental health homes have their own behavioral challenges to deal with. Including the patients into the education process and goal planning will go a long way. Be patient, but stick to it.

Diet

     Let me start out by saying don’t get freaked out about cooking for a diabetic. You won’t have to cook an entirely separate meal for your diabetic resident. Yes, you will have to make some adjustments, but we’re not talking about much. We’re just talking about cooking with a little bit more thought process in the menu plan. My wife is diabetic and has her blood sugar is under control. and guess what, I’ve gained weight. In reality, the average In Home caregiver, for the most part, cooks the way you’re supposed to cook any way. Plus, you’re not alone in this. Most insurances will pay for a diabetic educator and a dietician to consult with about your meal planning. I hope that takes care of some of the fear of the unknown for you cooks out there.  

     To help prepare you for your dietician consultation, let’s cover some food basics. Our body tries to convert most of what we eat into glucose. When the glucose concentration rises in the blood stream, our body starts to pump out insulin to take care of it. Some of the unused glucose is stored away as body fat. Some foods are readily converted to glucose while others have to go through a couple of steps and it takes longer. Parts of the foods we eat can’t turn into glucose or anything useable so it passes through our gut undigested as bulk fiber. We count on this bulk for proper intestinal function. 

Glycemic Index

     The glycemic index is a measure of the effects of carbohydrates in food on blood sugar levels.  Foods that are quickly converted to glucose result in a quick jump in your blood glucose concentrations. This is known as high on the glycemic index. In diabetics, their impaired insulin system is easily overwhelmed by the sugar spike, which results in all the unhealthy consequences of diabetes. For the most part, this type of food is  carbohydrates - breads, pasta, potatoes, white rice, table sugar, etc. If the food takes longer or is harder to digest, it results in a delayed or lower glucose spike. This means the food is lower on the glycemic index and the impaired insulin system is better able to handle it. I bet you have already guessed what some of these foods are. Yep, fruits, vegetables, whole grains, etc.

To Eat Fat or Not to Eat Fat,  That Is the Question.    

      We are learning more and more about fats all the time. After decades of research, we have found that a totally fat-free diet doesn’t really offer the benefits that people once thought. For some, it even caused some health problems. So fat free is out.  Is fat “in” now?  Yes and no. Let me explain.

     There are different kinds of fats. There are saturated, unsaturated, and trans fats. Saturated fats are big fluffy molecules that don’t compact easily in the blood stream. They are one of the contributors of LDL molecules (remember the cotton molecule). Unsaturated fats compact easier and result in HDL. HDL has been called the garbage truck because they can scavenge LDL and take them to the liver for disposal. Trans fat is the bad fat. We can’t use trans fats very well and they float around collecting in places. Trans fats are strongly associated with diseases. Of course, it’s a lot more complicated than this, but the take-away message is unsaturated fats- good. Saturated fats –so so, trans fats –bad. Good sources of the unsaturated fats are olive, peanut, canola, sunflower oil, nuts, fish, soybeans. Sources of saturated fats red meat, lard, butter, whole milk products like ice cream.  Trans fats are found in margarines, deep fried fast foods, processed snack goods. Yep, you’re right- good fats are in vegetables and lean meats. Bad fats are in highly processed convenience and fast foods. 

Let’s Wrap Up All This Talk About Food

     That’s enough talking about individual nutrients. After all, people don’t eat nutrients, we eat food. In general, a diabetic diet is just good old wholesome home cooked meals. Heavy on the vegetables, fruits, whole grains, moderate on the meats, whole dairy products, and controlled portions of high glycemic index foods like breads, pasta, potatoes, table sugar, and avoid fast and convenience foods. That is not much of a stretch from the menu that most of you cook right now. Your dietician or diabetic educator will explain things in more detail and help you tweak what you’re doing now. You’ll probably find that it’s a good idea to keep all of your residents are on a diabetic-inspired diet.

Exercise

     Another way for caregivers to help manage their patient’s diabetes is through enabling them in exercise therapy. Exercise manages diabetes by: 1. Improving the body’s use of insulin. Continued moderate exercise can help the muscles take in glucose up to 20 times their normal rate. 2. Helps to eliminate excess body fat (a major determinant in diabetes). 3. Increases energy levels to help maintain a more active lifestyle. 4. Reduces stress and thus reduces stress hormones that influence insulin and glucose release. 5. Improves the patient’s circulation.  Exercise even lowers bad LDL lipids and increases good HDL lipids.

How to Start

     Exercise is therapy and a doctor should be consulted before starting. The CDC recommends 30 to 60 minutes of physical activity on most days of the week. But you don’t have to start out that way and you don’t have to do it all at once. It is recommended that you start low and go slow, gradually working your way up to the target exercise goal. Working your exercise program in this way is easier to start, easier to maintain, and easier to establish good habits. One suggestion on low and slow is to exercise in spurts, for example 10 minutes three times a day.

Precautions

     Adult Foster Care geriatrics, Developmentally Disabled and Mental Health Homes all have their own set of challenges stemming for the unique characteristics of their client base. Use your own skills to adjust the program to meet the needs and abilities of your residents. There is no magic one-fits-all routine, and in all honesty, therapy doesn’t even have to be set exercises. Gardening, dancing, and washing a car are exercise, too.

     It is possible to exercise too much. Long bouts of intense exercise can actually increase blood glucose. Some patients are extra sensitive to exercise and it makes their blood sugars crash down to dangerous levels -hypoglycemia . Hypoglycemia usually happens gradually. Look for increasing signs of feeling shaky or anxious, light headedness, or  sweating abnormally. These are signals that the body needs more fuel and is easily managed with a high glucose tablet or snack. It is wise not to exercise during the peak effect of medications, especially short-acting insulin. Supply plenty of water during and after exercise sessions. If the patient exercises away from home, be sure to have a diabetic bracelet and emergency supplies with them. Always warm up and cool down with more intense routines.

Integrate in Normal Routines

     Some insurances pay for health club memberships, and some patients’ family have memberships. Take advantage of such resources. Outings to community pools are also a good (and cheap) activity. You certainly don’t have to turn your home into a spa. It is interesting to note that newer residential care and nursing facilities all have exercise facilities and they tout such in their advertising materials, (hint- hint). A cheap way to do this in your home is to go to Goodwill and pick up a used tread walker or stationary bike. Place the equipment by the TV and have a scheduled exercise period. Of course, walks are always a winner on many levels.

     It is  important  to make exercise a part of the scheduled routine. Routines become habits and habits are easier to maintain. Remember that you can substitute other activities to combat exercise boredom.

     Regular exercise helps manage diabetes, but there are other benefits as well. It improves muscle tone and balance ( fewer falls). It reduces stress and increases mental health, it improves self-esteem and combats depression, it strengthens the heart and bones, and it lowers blood pressure. The patient will realize these benefits even if they never lose a pound of excess fat. Bottom line, just start and keep at it. You will be doing good care for your residents.

Hygiene

      Taking care of oneself is much more important for the diabetic patient. The consequences of letting things slide are just too great. For example, poor foot care in diabetes can lead not just to smelly feet but infection and gangrene.  Diabetes is the leading cause of amputations. Of course, I don’t have to say it, but good personal care is the bread and butter of any successful Care Home.     

Smoking

     It is common knowledge that smoking is bad. Smoking and diabetes (and a lack of exercise)  don’t mix well. Don’t smoke - enough said. You can get medication to help combat the addiction. You, the caregiver, can control the environment, which certainly goes a long way. Make it very inconvenient to smoke. Those working in mental health environments will have the roughest time because there is a strong correlation between several mental illnesses and smoking. Get help from the doctors.

Hygiene

     Proper hygiene is one of the essential duties for any In Home caregiver, but it is particularly important for diabetics, who present problems with circulation, hydration, nerves (especially in the extremities), and immune system. Minor cuts, skin abrasions, or gingivitis can quickly turn into major problems.  Regular, full inspections, especially of the feet, are “must-dos” in diabetes care.

Oral

     Use a soft bristle toothbrush (medium and hard can lead to cuts and abrasions). Brush at least twice a day and floss daily.  Replace the toothbrush every three months. Remove and clean dentures daily. Chronic bad breath may be a sign of mouth infections and tooth decay.

Skin

     Dry, flaky skin is a constant issue with the elderly and diabetics. Applying lotion on a regular basis helps solve this problem and provides an opportunity to inspect the skin. The act of applying lotion soothes the skin and promotes blood flow. Warm and red patches are early signs of infection. Moisture on the skin leads to early breakdown. Adult diapers must be properly and frequently changed. Sedentary patients who never change positions can experience a lack of blood flow to the skin. Portions of the skin die and open wounds (“bedsores”) result. This can be managed by shifting the patient’s body position frequently. A rolled-up towel alternately placed under one side and then the other works well. 

Feet

     Foot problems are a particular challenge for diabetics. Numbness and lack of circulation put the diabetic at greater risk for infections in an area of the body that sees a lot of wear and tear. Remember: diabetes is the leading cause of amputations. Daily foot inspections are a very good idea.

How to inspect

     Look at the top and bottom of each foot. Check between the toes and look at the toenails. A mirror might speed the process for self-inspections. Look for cuts, blisters, ingrown toenails, or any signs of infection, such as moist or wrinkly skin between the toes. Don’t be surprised if the patient can’t feel the problems that you find. Numbness in diabetes is common. 

Corns and calluses are caused by friction or pressure against the skin. They can become dry and cracked, providing an opportunity for infections to develop. They should be removed by the gentle use of a file or pumice stone. If they keep returning, think about changing shoes and watch how the patient walks.

Thick toenails might be caused by a toenail fungus and they become a site of future athlete’s-foot infections.  If you intend to tackle the thick toenail fungal infection yourself, plan on at least 12 months of treatment. Toenail infections are particularly hard to get rid of.  Of course you’re not alone on the care team.  Podiatrists have the knowhow and proper tools.   

Tingling and sensitive feet are a problem for diabetics. You can get soft, seamless diabetic socks and special shoes. Some insurance plans will pay for them. Keeping the feet elevated can also help. There are numbing creams and mild capsaicin lotions that might also help and you could have a discussion with the doctor or podiatrist about them.

Monitoring

Signs and Symptoms

     Diabetes has been called a silent disease because the initial signs are not seen or felt. You as a caregiver must learn to see the early warning signs. Being cranky, bad tempered, or confused might be the result of hyperglycemia or hypoglycemia. Other signs of hyperglycemia (too much blood sugar) are frequent urination, extreme thirst, blurred vision, or unusual fatigue. Signs of hypoglycemia (low blood sugar) are frequent yawning or lacking energy, an inability to speak or think clearly, loss of muscle coordination, sweating, twitching, seizure, fainting, feeling like you’re going to pass out, or becoming quite pale. Have the doctor include in your care plan what to do in both cases . Make sure all substitute caregivers are trained in the details.     

Blood Glucose Monitoring

     Diabetics have been called “lucky” as far as chronic diseases go, because the patient can use a home glucometer to get a near-instantaneous blood-sugar reading to see how well they are doing. Finger sticks can take a lot of the guess work out of caregiving. If there are any unusual signs, symptoms, or changes in your patient’s condition, you can take a finger stick and see whether the blood sugar is too high or low.

     Readings can also help you tweak a menu for optimal results. For example, my wife found out that dishes with rice and ham sharply elevate her blood sugar, so she eats smaller portions of that combination and fills up on vegetables.

     Home monitoring of blood-sugar levels can also help you manage optimal exercise times, determine medication effectiveness , and decide a new medication is doing what it is supposed to do.

     Monitoring also gives you a common point of reference when communicating with other members of the care team and the patient’s family.  For example, the ideal communication might be, “Mr. Smith is not doing very well today. After a period of confusion, I checked his BG and found it was 60. I gave him a glucose tablet as per instructions in the care plan. This has happened several times this week. Doctor, I think you should review his medications.” Compare that to “Doctor, my patient is feeling cranky and acting strangely, What can you do about it?”. See how powerful BG monitoring results are and how professional they make you appear. 

Blood Sugar Monitors (Glucometers)

     Most often, your resident will already own their own glucometer. If so, find the owner’s manual and read it. Unlike other manuals, these are written so that anyone can use them. I recommend finding the toll-free help desk telephone numbers. The help desk operators are really quite helpful. If you don’t have an owner’s manual, go to the company’s website, find the help desk number, and ask for a new manual.  Or just get a new machine (more about that later).

     Next, inspect the machine. Does it work? Is it clean? Do you have all the parts? Use the manual as a point of reference for answering these questions. If it doesn’t work or starts to act strangely, check the battery (usually a watch/hearing aid-style battery. You can usually find replacements in the electronic sections of department stores. Etched on the battery are identifying marks that tell which type to buy.

If error messages appear, refer to the owner’s manual. Clean the meter with soap and water using a wash cloth. Alcohol pads are ok, but it can be tedious to use those to clean. Wear gloves (after all, you’re dealing with blood). Look for the lancet device and lancets (the needle-like tools you place in the device that usually looks like a pen). Unused lancets have a twist-off top. You can buy the lancet device and lancets separately if they are missing. When making such a purchase, be sure the device and lancets match.

Every machine will be different but the basic instructions are:

  1. Place a lancet in the lancet device. Hold the device next to the skin. Avoid sensitive spots like finger tips to make the test less painful. The sides of the fingers have fewer nerve endings. Click the lancet trigger. If you don’t get blood you can: adjust the lancet depth gauge (to puncture a little more deeply), swing the hands around to push blood to the fingertips, “milk” the fingertip by squeezing it after puncture, or try another spot. A point of caution when choosing alternative sites: Different points of the body can give different readings. Blood from the arm might be different than blood from the fingers. Consult with your doctor or diabetes educator.
  2. Place a drop of blood on the strip. For most machines, the strip should first be placed in the machine. Review the owner’s manual.
  3. The reading should only take seconds to appear. Record the data. If the reading is off, repeat to verify.

 

New Machines

     There are more than 25 glucometers on the market. When it comes right down to it, the brand really doesn’t matter as long as you learn how to use it and are comfortable with it. 

     The cost of the machine is almost irrelevant. Insurance plans typically pay for the machine or you can get one free from the manufacturer. If you do have to shell out some cash, pay particular attention to the cost of the test strips. Insurance plans also typically pay for the strips.

     Determine which brand the insurance company prefers and you’ll save yourself a lot of hassle. On the back of the insurance card, you’ll find a toll free number that you can call and ask about brand preferences.

      If you want the insurance plan to pay for testing supplies, you need a prescription. To save you some troubles, have the doctor write generically. For example, it’s better to write “Diabetic testing machine and supplies, refills for a year.” When the doctor writes the Rx like this, the pharmacy has greater latitude and they can make brand adjustments as needed if any difficulties arise or the patient switches insurance carriers.

Newer glucometers have many features. Don’t get caught in the “Shiny New Object” syndrome. If you’re never going to use all the doodads, why buy a machine that has them. Overall though, just relax. You’re going to have plenty of time to learn to use and become comfortable with this technology. The diabetic educator will be useful in helping you learn about the whole testing process. The rest of the care team can help, too.

Final Note on BG Testing

      The doctor will help you decide when and how often to test. Be sure to cover the subject with him or her and get it in the care plan. There will be times when you need to test outside the regular schedule. I recommend getting an extra box of “just in case” strips so you don’t have to dip into the regular supplies. Insurance companies can be an awful pain when it comes to early refills. 

 

Other Monitoring

 BP and Weight   

     Other signs to monitor at home include blood pressure and weight. Many aspects of diabetes affect the blood system. Monitoring the BP can help you manage diabetes and the patient’s overall health. Monitoring weight is useful for assessing the long-term effects of care. Be sure to record all your readings in the care plan.

Medications

     Don’t forget to monitor the effects of the medications. Are they working?  Your finger stick readings will help determine if they are. The timing of medicines is an important factor as well, especially with short-acting insulin. Learn about the whens of dosing. The timing will affect when to exercise, when to eat, and when to travel outside the home. Medication timing can even affect the therapy itself. For example, sometimes just changing the administration time can solve therapy problems . Keep in touch with the doctor about any such concerns.

     Are there side effects? The paperwork from the pharmacy will tell you what to look for. Communicate any observations to the doctor. Don’t be surprised if the doctor says they’re not going to do anything because the side effect doesn’t outweigh the benefit of the drug. Of course, you have a different perspective:  You live with the patient and the doctor doesn’t. Don’t be afraid to battle for your client, but be professional about it.

Environment

     And the final factor to monitor is the home environment. Watch for things that can nick or cut “at-risk” feet. Stress affects diabetes. Be aware of the overall stress of the home or the stress level when visitors arrive. It is wonderful for loving friends and family to visit, but they can also attempt to slip the patient a few extra unplanned treats and snacks. In diabetes, loving someone to death takes on a whole new meaning.  

Step 4 Get Routine Care

     As part of the overall care strategy, you must track routine scheduled visits to other health providers. A diabetic should see their prescriber at least twice a year. the A1c level should be tested at least twice a year as well. Annually, the patient should receive a lipid panel, a foot exam, a dental checkup, and an eye exam (although not all at once, of course). Immunizations should also be performed according to recommendations, such as annual flu shots every year, and pneumonia vaccinations every five years.  That is a lot to keep track of. The most logical place to manage all these visits, records, events, and schedules is in the diabetes care plan in the patient’s folder. It is an excellent place to keep all the necessary records and schedules. You can pull it out whenever the patient goes to the doctor, or when other healthcare professional visit your home.

Conclusion

     As a member of the diabetes healthcare team, the caregiver must learn the special needs of the patient and how to take care of them.  The four-step plan from the Centers for Disease Control is an excellent starting point.  Working with other team members, the caregiver can establish an individualized care plan that will help the patient remain healthy for a long time.  I hope this CE has started you path of good caregiving.

Mark Parkinson RPh.

 

References:

1. National Diabetes Fact Sheets 2011, Center for Disease Control

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf             

2. Diabetes diet: Create your healthy-eating plan, MayoClinic.com

http://www.mayoclinic.com/health/diabetes-diet/DA00027

3. Easy Menu Planning , Save Time and Money with Meal Planning  Squidoo.com

http://www.squidoo.com/easy-menu-planning

4. Type 2 Diabetes: Meal Planning, University of Michigan Health System

http://www.med.umich.edu/1libr/aha/ummp2.htm

5. The Basics of a Healthy Diabetes Diet, Diabetes Health Center. WebMD.com

http://diabetes.webmd.com/diabetes-diet-healthy-diet-basics

6. Margaret Farley Steele, The Diabetes Caregiver: Diet. Caring Today .com

http://www.caringtoday.com/deal-with/the-diabetes-caregiver-diet

7. Sarah Henry, How to Help Someone With Diabetes Stick With Diet Recommendations. Caring.com

http://www.caring.com/articles/food-recommendations-for-diabetics

8. Fat, Wikipedia.org

http://en.wikipedia.org/wiki/Fat          

9. Blood glucose monitoring, PubMed Health, US National Library of Medicine

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003911/   

10. Vegetable Fats and Oils. Wikipedia.org

http://en.wikipedia.org/wiki/Vegetable_fats_and_oils

11. Fats and Cholesterol: Out with the Bad, In with the Good. The Nutrition Source, Harvard Public School of Heath. Harvard.edu

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-full-story/index.html

12. Diabetes: Keeping Up With Your Active Life. WebMD.com

http://diabetes.webmd.com/active-life/slideshow-managing-diabetes-10-tips

13. Type 2 Diabetes and Exercise, Diabetes Health Center, Web MD.com

http://diabetes.webmd.com/guide/exercise-guidelines

14. Food and drug administration, Diabetes: Choosing and Using Your Glucose Meter, MedicineNet.com.

http://www.medicinenet.com/script/main/art.asp?articlekey=20554

15. Diabetes, Diabetes and Exercise.The Family Doctor.org     

http://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/treatment/diabetes-and-exercise.html

16. Major depression, Depression and anxiety: Exercises eases symptoms. MayoClinic.com

http://www.mayoclinic.com/health/depression-and-exercise/MH00043

17. Diabetes, Helping a Family Member Who Has Diabetes. The Family Doctor.org

http://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/treatment/helping-a-family-member-who-has-diabetes.html

18. Hygiene, Bayer Diabetes

http://www.bayerdiabetes.ca/en/diabetesinfo/control/hygiene/

 

Diabetic in my Home – Now What Do I Do?

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“Ouch”, it hurts when I smile.

Those darn cold sores!

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Educational Goal

To give an instructional overview of cold sores

Educational Objectives:

1.  Give a description of what is a cold sore.

2. Tell how to treat cold sores.

3. Tell when care giver should respond to a cold sour outbreak

Procedure:           

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

  Disclaimer  -    The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

“Ouch” it hurts when I smile.

Those darn cold sores!

 

Those darn cold sores!

     Cold sores, fever blisters, or recurrent herpes labialis are those annoyingly painful blisters that form around the lips. They break out, leak fluid, and crust over.  Before they go away, scabs form that are none too flexible. They often crack when you move your lips, adding to the painful annoyance.  Just what are cold sores? Where do they come from? Can I get rid of them? Can I prevent them from happening in the first place? As a care provider, should I even care?

What are cold sores?

     Cold sores are lesions that are the result of a reoccurring infection of the Herpes Simplex Virus (HSV). That’s right, herpes. You might have heard that name before associated with a sexually transmitted disease. You’d be wrong to worry, though, because there are two types of HSV.  Simply named HSV-1 and HVS-2.  HSV-2 is the bad one; HSV-1 is the more common form that causes most of the cold sores.

Where do they come from?

     Unfortunately, HSV is a very common, very contagious virus. It has been estimated that by age 50, 80-90 percent of adults carry the virus. More than 50 million people in the U.S. will have at least one outbreak this year. Everyone who has an outbreak can potentially spread the virus to anyone they come in contact with.

     It can be spread by direct contact, like kissing, or indirect contact. It can be passed along by sharing a drink or lip balm, or if the patient rubs the sore with his hands then spreads it by touch.  The virus can even spread through air-borne droplets of saliva from a sneeze. It is pretty safe to answer the question, “Where do they come from” by answering “from anywhere and anyone.”

How does the infection progress?

     Most people get their first exposure as a child or adolescent. It manifests itself as a fever with a severe sore throat, possibly with lesions that on the cheeks or gums. The body quickly develops antibodies to the virus and the symptoms fade. But the virus never completely goes away. There are places where it can hide and go dormant, waiting for optimal conditions to multiply and spread again. Its primary hiding place is the sensory facial nerves around the mouth.

     When a virus invades a cell, it will start to take over and make the cell produce more viruses. Eventually the cell dies or bursts, releasing thousands of new viruses. For the most part, the body’s defenses will swoop in and take care of things. That is why we are symptom-free, although we all carry the virus. But there are times when our defenses are down or busy elsewhere and a local outbreak happens and symptoms reoccur.

Cycle of an outbreak

Symptoms typically follow an eight-stage cycle.

  1. Latent or remission period: There are no symptoms. It can last weeks to months
  2. Prodromal: (day 0-1): Symptoms start to appear before the lesion does. Typically it starts with a tingling or itching along with redness around the infection site. This can last a few hours to a few days
  3. Inflammation (day 1): The virus tries to attack new cells. The body tries to defend itself with the inflammation response, essentially walling off the area and calling in the clean-up crew.
  4. Pre-sore (day 2-3): When the inflammation response starts to take care of all those new viruses, things get pretty crowded. Tiny, hard, inflamed vesicles start to form. They may itch and become painful. Soon, fluid-filled blisters form in a cluster, usually at the border of the lip and skin, but they can form on the nose, chin, or cheeks. (In case you’re wondering, only about 10 percent of cold sores develop away from the lips.) 
  5. Open lesion (day 4): The tiny blisters break open and become one large, irregular-shaped one. An all-out battle is occurring between the infection and the body. The discharge weeping from the sore is full of active viral particles that are highly contagious
  6. Crusting (day 5-8): The body is starting to win the battle and a hard scab starts to appear. But the scab cracks and breaks with lip movement causing more pain and virus-filled fluid to leak out.
  7. Healing (day 9-14): New skin is formed under the scab as the infection starts to resolve itself. Most, but never all, of the viral particles are killed off.
  8. Post-scab (12-14 days): The battle is all most over. A reddish area may linger as new cells are regenerated and the inflammation response is turned off.

What triggers an outbreak?

   In about one-third of those who carry the virus, a reoccurrence of cold sores can happen. In most people, the blisters form in the same area each time and are triggered by the same factors.  Common trigger factors or “stressors” include overexposure to the sun and other UV radiation sources; mouth surgeries; facial procedures like laser treatments, tattoos, and chemical peels; psychological stress; menstrual cycles; and immunosuppression.  Cold sores that are sun-induced tend to be more severe in pain and duration.

What can you do for cold sores?

     There is no known cure for HSV-1, but since patients are largely symptom-free, it just doesn’t matter.  But what do you do about those annoying cold sores when they pop out?

Cold sore treatment options

A. Do nothing. Cold sores are self-limiting and they resolve themselves after about 14 days.

B. Treat yourself. There are several OTC medications you can use to feel better. There is no “one-drug-does-all” medicine, so you must know what each one does and chose your therapy wisely.  Here is a list of the different kinds of OTC medication by group.

  1. Docosanol (Abreva). This is the only OTC medication approved for the healing of cold sores. It works by blocking the virus from entering cells. It heals about as well as prescriptions and costs about $15. It cuts the severity of the outbreak but only lessens the duration by about a day or two. You must apply it five times daily for no more than 10 days. It does nothing for the pain, but the cream base might help the scab from cracking.
  2. Pain relieving pills. We all have our favorites - no use in listing all the benefits and side effects. The idea is to use them to reduce the pain. One note, though: acetaminophen (Tylenol) does not reduce inflammation.
  3. Topical agents. There are plenty of creams, ointments, and solutions with medicines that numb, dry up the sores, or keep the scab pliable to prevent cracking.  I really don’t have a preference myself, though I can tell you that 20-percent benzocaine is probably the most potent numbing agent.  The following is an incomplete list of the products I know about. Anbesol cold sore remedy, Blistex medicated lip balm, Campho-Phenique with drying action, Carmex, Chap Stick cold sore therapy, Herpecin L, Lip Clear Lysine +, Neosporin LT, Orabase, Zilactin,
  4. Moisturizers. Pharmacists recommend keeping the area moist as the lesion begins to form a crust. If the lesion cracks, it may be more susceptible to secondary bacterial infection that can slow   healing. Common skin protectants, such as petrolatum and cocoa butter, can be used to keep the area moist.
  5. Other treatments.  Tooth-numbing agents would probably do in a pinch, although all numbing agents wear off fairly quickly. Lysine has been used for a long time on cold sores but scientific studies done with it just does prove it actually does anything. Zinc can prevent viruses from multiplying, but here again, there isn’t much proof that it works on cold sores. For herbals and homeopathic agents, you’ll have to decide for yourself because there isn’t much scientific evidence one way or another.

C. Prescription antivirals. Topical (acyclovir cream, penciclovir cream) and oral (valacyclovir, famciclovir) antiviral agents are effective in reducing the viral load of an outbreak and reducing the severity of the infection. But for maximum effect, therapy should start within the first two days of infection. A quick response becomes problematic when doctor appointments are involved. Because the of self-limiting nature of cold sores, there are those who say that doctors should only be called when there are serious complications or reoccurrence is very frequent.

Can you prevent cold sores?

The answer is yes and no.

Yes: By avoiding “stressors,” it is conceivable that you could avoid some cold sores. Of course that would mean that you have to know what events trigger your individual outbreaks. You’ll need to pay attention and keep good records. If you have frequent outbreaks, it might be worth the effort.

No: Sometimes bad things just happen and you have no control. Certainly, a healthy lifestyle goes a long way, but who can completely control everything that happens to them?

As a caregiver, should I even care?

     From a caregiver’s point of view, the real question is, when should I care? A cold sore can be painful and embarrassing, but it’s not a serious infection. From my perspective, I take care of those who are under my charge. Their condition is a direct reflection on my caring skills. The way a client looks and feels is the most potent advertisement of my skills. Beside, that’s what I do - care for people.

     Still, there are those times when even a cold sore can be a serious infection.

  1. Frequency of cold sores. Outbreaks usually occur less frequently after age 35. If you see an increase in frequency, it could be a warning sign. A more serious health event might be happening. It would be a good idea to I would notify the doctor.
  2. Patients who are immunocompromised may suffer from severe complications such as encephalitis. For those who are at greater risk the wise saying is “When in doubt-send them out” to the doctor that is.
  3. It is possible that every cold sore infection could be spread to the eye where serious problems could rise. Be aggressive in therapy if the eye starts to get red or goopy.
  4. There are some other infections that may look like a cold sore infections. It would be important to know how to tell them apart. Two possibilities are canker sores and impetigo. Canker sores happen exclusively in the mouth and are really a mouth ulcer. Cold sores are rare in the mouth and happen in the same location over and over again. Impetigo is a skin infection most commonly seen in children. It causes blisters around the nose and mouth. If a blister happens around the nose I would send the patient to the doctor.

     One Final note to the care giver. The main cold sore battle happens in the first two days. It’s a priority that therapies should start then. Since the site of the cold sore and the symptoms are predictable it shouldn’t be too difficult to be prompt with therapy. To cover bases, if cold sores happen often I would get some standing doctors in the records on what to do.  

  Conclusion

     HSV-1 infections are not usually serious but often painful and annoying. The infection will usually resolve itself in about 14 days. There are several things a patient or a caregiver could do to lessen the severity of an outbreak. Prompt action within the first two days of a cold sore is the most effect therapy. Rare but serious complications and look alike conditions should be handled by a doctor.

 

References:

1. Elena Beyzarov, PharmD,,Addressing Common Oral Ailments: Current and Emerging Treatments for Herpes Labialis, Aphthous Ulcers, and Xerostomia. Pharmacy Times ACPE Program 0290-0000-12-86-HO1-P

https://secure.pharmacytimes.com/lessons/201209-01.asp

2.The Free Dictionary by Farlex

http://medical-dictionary.thefreedictionary.com/cold+sore

3. Wm Opstelten MD, Arie Neven  MD, Just Eekhof MD, Treatment and prevention of herpes labialis, Canadian FamilyPhysican 2012                                                                 

http://www.cfp.ca/content/54/12/1683.full                                                                               

4.  Herpes labialis. Wikipedia The Free encyclopedia

http://en.wikipedia.org/wiki/Herpes_labialis

5.Cold Sores: Patient Education Series, Brown University Health Services

http://www.brown.edu/Student_Services/Health_Services/library/documents/ColdSores11.pdf

6. Barbara Sax, Cold sores and canker sores? What is the difference?,Pharmacy Times.Nov.1 2004

http://www.pharmacytimes.com/publications/issue/2004/2004-11/2004-11-4707

7. Mohamad El Mortada  MD, MaryAnn Tran  MD, Corrine Young  PharmD, Mary Nettleman, MD, Cold Sores.EMedicineHealth.com

 http://www.emedicinehealth.com/cold_sores/page6_em.htm

8.Melanie Cupp,PharmD. PL Detail-Document, Treatment of Cold Sores. Pharmacist’s Letter/Prescriber’s Letter. May 2011. Melanie Cupp, Pharm.D.,

 

“Ouch”, it hurts when I smile.

Those darn cold sores!

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What Your Pharmacist Didn’t Tell You.

Safety Guidelines for Medications

 

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Educational Goal: 

To instruction on medication guidelines not normally given to care givers.

Educational Objectives:

1. List the drugs with special handling instructions.

2. List the drugs that have to be refrigerated.

3. Example how to use spay inhalers

4. Tell how to legally dispose of drugs

5. Give instruction about which drug that shouldn’t be crushed

 

Procedure:          

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

 

Disclaimer  -    The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

What Your Pharmacist Didn’t Tell You

Safety Guidelines for Medications

 

 

      How often do you talk in-depth with the doctor about the medication your residents use? How much time have you spent with the pharmacist when your patient gets a new drug? How many times have you read through the literature that comes with the meds every month? If you’re like the vast majority of caregivers, the honest answer is probably- never, just enough time to pay for the drug and get home and “What literature? Oh, you mean those papers I throw away.”  Of course you’re not the only one who isn’t up to speed. How often has the doctor called you? How much time does the pharmacist spend with you? As for the literature- what is significant and what’s not? There’s a ton of boring reading that doesn’t seem important.

     The truth is, I should know better. I’m a pharmacist but I fall into the same traps myself time after time. Not enough and too much info at the same time. Unfortunately, it’s just something you’ll have to deal with. That’s the world of medicine we live in. The following article offers a few items I think are important that you may not know. I hope it helps in your caregiving.

 

Drugs with Handling Concerns

 

     The skin is a pretty good barrier to the vast majority of drugs that might come in contact with your skin, but there are a few you should watch out for. Pregnant females or those of child-bearing age are at most risk. Surgical gloves, medicine dispensing cups, and common sense are probably all the protection that is needed.

Those drugs are:                                      

All chemotherapy drugs. These are power drugs specially designed to kill cells. If you’re required to dispense them, don’t, not until you get detailed instructions.

Finasteride (brand names: Proscar and Propecia) can cause birth defects and feminization of the male fetus.

Testosterone and Estrogen can come in creams and patches and are designed to be absorbed through the skin – anyone’s skin, not just the patient’s.  Testosterone brand names include: Androderm, AndroGel, Axiron, Fortesta, and Testim.  Females and children should avoid even touching the application sites on the male. Estrogen brand names  include creams such as Estrace vaginal and Premarin cream . Patches include Alora, Climara, Estraderm, Estradiol Patch, Vivelle, and Vivelle-Dot.

Nitroglycerin brand name patches– include Minitran.  The cream  is NitroBid. These can cause headaches as a side effect even in caregivers who give careless applications.

A caregiver note about nitroglycerin sublingual (under the tongue) meds.

     Nitroglycerin is considered by some medical professionals to be addicting. it is  supposed to be a rescue medication for angina or heart attack – not a routine medication. If your resident insists on using them on a regular basis, they may be addicted. If they do need them all the time, time-released capsules or patches might be more appropriate choices.

 

Refrigerated Items

 

     There are a few drugs that break down quicker at room temperature. You see them stored at the pharmacy in their refrigerator. Ever wondered if you have to keep them in your fridge?

Commonly used meds that need to be refrigerated and what you need to know once you get them home:

Calcitonin nasal, brand name –Miacalcin. - Opened bottles may be stored at 59oF to 86oF in upright position for 35 days. –Fortical - After opening, store bottle in use in an upright position for up to 30 days at 68o to 77°F.

Benzoyl peroxide/clindamycin, brand name –Duac - Good for 60 days, unrefrigerated.

Latanoprost brand name –Xalatan - Can store at room temperature not to exceed 77°F  for up to six weeks. Off-label information indicates unopened bottle stable when maintained at continuous room temperature 77oF for 12 months.

Lorazepam intensol oral concentrate (liquid) - Off-label information indicates stable when maintained at continuous room temperature 77oF for 30 days.

Becaplermin cream brand name –Regranex - Off-label information indicates that unopened tubes left out of refrigerator are stable up to 86oF for up to six days or less, one time only.

Promethazine suppositories, brand name –Phenergan - Should always be stored in the refrigerator.

Insulin-type meds

Insulin is injected straight into the body, so special care has to be taken in its storage and use:

  1. Never freeze.
  2. Never expose insulin to direct heat or light.
  3. Inspect insulin before every use. Any insulin that has clumps or solid white particles should be thrown away. Insulin that is supposed to be clear should not have any cloudy appearance. If so, throw it away.
  4. Unopened, not-in-use insulin should be stored in a refrigerator.
  5. Opened, “in-use” insulin should be stored at room temperature below 86º F. Why? Injecting cold insulin can hurt.  
  6. Generally, vials of insulin can be stored at room temperature for 28 days. Easy-to-use pens can be considerably different - only seven days in some cases, up to 42 days in others.
  7. Do not ever assume you are using the correct insulin based solely on what it looks like or where it is stored. Always read the label before and after use. Avoid mistakes made by storage mix ups. Cut the prescription label off and throw away the box after you open them up.
  8. Insulin suspensions should never be shaken. Instead, roll the vial or pen cartridge in your hand to mix them up. 

For a more complete insulin storage guide, go to: http://www.dhs.wisconsin.gov/rl_dsl/publications/GudStrgInsulin.pdf

 

Inhaler Use

 

     Inhalers must be used correctly for maximum benefit, and it’s your job to see that they are used correctly. You can’t assume that the patient knows how to use them. There are a lot of people who think they know how but don’t.  Inhalers are packaged with instructions. Become familiar with them.

A few instructions that are easily missed:

  1. Prime spray inhalers (test sprays sprayed into the air) before first use or if inhaler has not been used for a while.
  2. Shake well before each use.
  3. Patients should rinse the mouth out after inhaler use, especially if they taste the medicine. This will help prevent fungal infections.
  4. If the patient has difficulties in using spray inhalers, have the doctor order a spacer or a spacer with a mask. They will make inhalers much easier and more effect to use. The spacer requires a prescription,. A warning though, a lot of insurances won’t pay for them.
  5. Clean the mouthpiece (plastic part of inhaler) with water and air dry thoroughly.
  6. If there are multiple inhalers prescribed at the same time, use the bronchodilator or “rescue inhaler” first. It will quickly open the lungs and the other inhaled medicines will go deeper into the lungs.
  7. Don’t forget to have the patient take their rescue inhaler with them on outings away from your home. If you don’t know which one that is ask. It’s usually the one with albuterol in it.
  8. Albuterol can make the patient feel jittery. The feeling goes away pretty quickly on its own. Young children don’t understand this feeling, and they can act like they’re hyperactive.

 

Don’t Crush or Chew Meds

 

     Pretty straightforward, but what if your residents chew up meds despite what you tell them, or what if you have to put the meds down a g-tube? If you have these or other cases that involve pill crushing or chewing, go over each med with the doctor. In general, medications you should be concerned about are pills that say extended, sustained, controlled, timed or slow release, enteric coated, sublingual (under the tongue), and all potassium pills. For most of these medications, if you have to crush them there are alternatives with the same therapeutic results.

   Special note about g-tubes and meds. Some medications adhere to the plastics of a g- tubes. Not all pharmacists and even doctors know which ones. Hospital and long-term Care pharmacies should know more about which meds wouldn’t clog a g-tube.

For a more complete do-not-crush  list, go to:  http://www.ismp.org/tools/donotcrush.pdf

 

What to do with Unused Drugs

 

     There is an ever-growing group of very stupid people who swipe prescription  drugs and use them to try to get a buzz. It doesn’t seem to matter if it’s a heart medication or laxative. Unused meds must be disposed of correctly. It used to be acceptable to  dump them down the toilet, but all those drugs in the sewer system started to affect the environment and gum up the public sewer system. The federal government issued the following guidelines:

Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so. For information on drugs that should be flushed, visit the FDA’s website.

   To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take-back programs or other programs, such as household hazard waste collect events that collect drugs at a central location for proper disposal. Call your city or county government’s household trash and recycling service and ask if a drug take-back program is available in your community.

If a drug take-back or collection program is not available:

  1. Take your prescription drugs out of their original containers.
  2. Mix drugs with an undesirable substance, such as cat litter or used coffee grounds.
  3. Put this mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag.
  4. Conceal or remove any personal information, including prescription number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off.
  5. Place the sealed container with the mixture, and the empty drug containers, in the trash.

 

Here is a website that lists drug collection locations for Oregon cities.

http://www.deq.state.or.us/lq/sw/hhw/DrugTakeBackSites.pdf.

 

 

Conclusion

 

     I hope you can use the information in this article for the betterment of your clients. If my words have made a difference in the lives of those who need help, I sleep better at night. Remember to get educated about the medications. They are powerful tools to help keep your patients healthy and functioning properly.

 

 

References:

 1. Pharmacist’s Letter Detail-Document#: 220339 Detail-Document#: 240406 Proper Use of Dry Powder Inhalers (DPIs)

2. Medication and Drugs. EMedicine Health

http://www.emedicinehealth.com/drug-estradiol_transdermal/article_em.htm

3 Stability of Refrigerated and frozen Drugs Pharmacist’s Letter detail-Document#:241001. October 2008. Volume 24. Number 241001

http://www.ashp.org/DocLibrary/Policy/PatientSafety/FrozenDrugs.pdf

4. Guideline for Insulin Storage. Department of Health Services .State of Wisconsin

http://www.dhs.wisconsin.gov/rl_dsl/publications/GudStrgInsulin.pdf

5. Proper Disposal of Prescription Drugs. Office of National Drug Control Policy 2009

http://www.nodakpharmacy.com/pdfs/prescrip_disposal2009.pdf

6. John F Mitchell, Oral dosage forms that should not be crushed. Institute for Safe Medication Practices Mar 2012

http://www.ismp.org/tools/donotcrush.pdf

7. Insulin Safety in Your Home. Consumer MedSafety .org

http://www.consumermedsafety.org/insulin-safety-center/item/497     

 

 

What Your Pharmacist Didn’t Tell You.

Safety Guidelines for Medications 

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Oh my ACHING Back! The Dangers of Lifting

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 2- Approximate time required: 120 min. 

Educational Goal:

  To give instructions on how to lift correctly without injury

Educational Objectives:

1. Explain why back injuries are so serious.

2. Explain the Supervisor role in training and lifting education.

3. List and Describe Lift resources and equipment.

4. Present a lift training program.

5. Explain what to do in patient falls

Procedure:            

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

 Oh, my ACHING Back! The Dangers of Lifting

 

“Help, I’ve Fallen”  

     You have seen the commercials on TV. An elderly woman yells, “Help! I’ve fallen and I can’t get up.” If that scene was shot in a care home, you would hear the patient yell followed shortly by the caregiver yelling even louder, “Help, my resident has fallen and I threw out my back trying to get them up.”  Every job has its hazards. For In Home caregiving, especially elderly care, back injury is an ever present danger, a career stopper, and a business killer. Proper patient transferring and lifting techniques are the only sure ways to protect yourself, your business, and the patient from further injury.

Healthcare Workers Sustain More Costly Lifting Injuries

     At first glance, caregiving may seem like easy work, but In Home caregiving can be very physically demanding. Whether you’re in adult foster care, developmental disabled, or mental health homes, there always seems to be the need to pick up someone who’s fallen, assist in transferring, bathing, or lifting heavy supplies and furniture.  These manual lifting tasks have the potential to and have caused significant pain and injury to care workers and care home owners.  Healthcare industry workers sustain four-five times more overexertion injuries than any other type of worker. 

     Back injuries are expensive, too. Nationally, an average lower back injury runs about $24, 000.00. If surgery is involved, the cost jumps to an average of  $40,000.00. Even with worker’s compensation insurance, the costs of increased insurance premiums, time, pain, and absenteeism from work is very high.  With the costs so high and potential injury so great, patient transferring, preventing falls, and lifting heavy items  should be a priority concern for any In Home caregiver.

Ergonomics for the Prevention of Injuries

     Ergonomics as defined by OSHA is “the science of fitting workplace conditions and job demands to the capabilities of the working population. Effective and successful ‘fits’ assure high productivity, avoidance of illness and injury risks, and increased satisfaction among the workforce.”  In layman terms, that means to establish work training and work practices that everyone can live with that prevent injury. It is the duty of home care owners to establish these programs. The content of this CE is written with the intent that it could be utilized as part of a training program for care homes.  I give permission for care homes to copy and use any or all of this article for their own or business use.

 

In-Home Caregiver Program - Patient Transferring, Lifting, and Falls

 

Information for Owners - Management Involvement

No program will last for long without the involvement of the boss. Owners of care homes should:

1. Establish practices and policies for safe patient handling.  Owners have to communicate to everyone how to properly and safely lift.  You’ll find the easiest way to accomplish this goal is by a setting up a program that everyone has to go through. Elements of such a program are A) communicate the importance of proper techniques. B) a training program C) a test to demonstrate knowledge gained D) follow through.  One idea for training and testing is for the owner or other caregiver to become the patient.  Showing and actual hands-on practice, along with reading, is a powerful way to teach. 

2. Supply the proper equipment and resources to accomplish the lifting task. I think I just heard a collective moan form the owners’ wallets. While it is true that a small business must keep expenses down, you’ll find that the proper tool at the proper time does save more money than the tool itself. An inexpensive transfer belt is a lot cheaper than increased worker compensation premiums. More on equipment later.  A lot of resources don’t cost any money. These include team lifts. The more bodies that lift, the easier the lifting task is. Owners must establish an environment where workers can ask for and get the assistance they need. If you are getting those types of phone calls, your lifting program is working.

3. Follow through. It’s one thing to establish a program. It is another to do the program, employee after employee, year after year.  A check-off form attached to the employee’s file will help. Make it a habit. Also keep track of the equipment. Make sure it doesn’t walk off on its own or need repair. Periodically, it is good to ask questions of your employees. Ask them what they need, which tasks are the hardest, should the home be rearranged to make the job easier or safer. This accomplishes two things. Employees can sometimes come up with some pretty good suggestions. It strengthens employee-owner relations. Follow through is simply a good business practice.

4. If an injury occurs, reporting it should be one of the first steps. The owner has to create an environment where the employee feels safe reporting an injury.  Once informed, the owner has to report it to their workers compensation insurance program. It’s the law. Failure on either count might lead to denial of a claim, negligence charges, and law suits or worse.

Lifting and Transferring Equipment

     With medical costs and insurances skyrocketing, large nursing homes and hospital corporations are spending millions on new lifting equipment and implementing no-lift policies. Care homes do not have those resources but some savvy owners are upgrading their own homes in a more cost effective way.  Make connections with the large health institutions’ equipment managers in your area and you might pick up a good deal on used equipment. Also, keep an eye on the second-hand stores where some medical devices can be purchased for pennies on the dollar.  You might advertise on the Internet or local newspaper  to purchase used equipment.

New patient transfer equipment that is well within the reach of most care home budgets include:

Transfer or Gait Belts

      Traditionally, these were belt-like devices made out of canvas with a metal cinch clasp on one end. It was placed around the hips of the patient, giving caregivers a convenient place to hold on to. While those old belts can still be purchased for less than $5.00 a piece used, they are being replaced by gait belts with a superior design.  The new designs are two to three times as wide, made of easy-to- clean synthetic materials, a quick-release plastic clasp, and multiple  soft handle loops  sticking out. They are easier to use and clean than the older version. They cost a bit more, but new units cost less than $40.00.

Transfer Boards

     A transfer board is any material or object that can hold up under the weight of the patient that they can slide on to get from one place to another. Literally, a highly polished board with a good finish will do the trick. Commercial versions are much easier to use for the caregiver and the patient. Transfer boards come in astounding  varieties, ranging from simple ones running about $10-20 to extremely versatile or specialized units going for hundreds of dollars.

Swivel Boards or Discs

     These devices are placed under the feet of the patient to assist in turning in the pivot-transfer method. They are designed to function even with the heaviest patients.  Quality units run hundreds of dollars.

Transfer Benches

     A transfer bench is a cross between a bath bench and a transfer board.  All are designed to be bath capable. The simplest are just bath benches that are long enough to extend over the bath tub side wall. Used versions can be picked up inexpensively. More advanced versions come complete with swivel chairs mounted on rollers. They make bathing your residents very easy and virtually fall free. They run up to $500, depending on how many features you want. Good units can be purchased for around $200- $400 each.

Power Lifts

     Power lifts are any powered device that aids in a patient standing or transferring. These are the most expensive, with some devices running thousands of dollars.  The most common versions in care homes are power lift easy chairs that residents bring with them from home. Make arrangement to purchase used chairs when a client moves on. Or better yet ask, the family member donate the chair.

Stand-Assist Devices

     Stand–assist devices are basically handles that the patient holds on to while they stand. The patient uses them to pull themselves up.  The model can be free standing, fixed to a bed, or chair. There is even a version that attaches to the top of a car door that makes it easier to get in out of a car. These are simple devices and most can be purchased for $100 or less. These are the easiest to pick up used.

Insurance Coverage

     Depending on the patient’s diagnosis, some devices are covered by insurance.  Durable medical device salesman can assist you in the particulars of the paperwork.  A  prescription will likely be needed.  It would be to your benefit to learn about the insurance process so you can utilize the coverage in similar future circumstances.

 

Training Program

Overview

     Every year, thousands of healthcare workers go to work to help their patients only to have a lifting injury and become a patient themselves. It is ironic that the act of assisting the patient, if not properly done, may cause harm to that very patient. To help keep you and your charges from unwanted injury, the following program was developed.

Awareness

     In-home care giving may seem like an easy job, but at times it can be quite physically demanding. The caregiver must take the responsibility to always be aware of what is required of them and accomplish those tasks safely. Do not fall into the trap of doing things the quick and sloppy way. Such thinking has led to many patient injuries, caregiver back surgeries, and lives full of pain.

     If an injury does occur, report it immediately. A stitch in time really does save nine. No one wants to see you hurt or work while you are hurt. Call the management at any time when there is a need. Help will always be there for you.

Limitations

     Remember that when you work with the elderly or bed ridden, inactivity and osteoporosis robs the bones of their strength and makes them brittle. Arthritis can result in sore and stiff joints, making regular movements difficult.  It’s easy to get dizzy if you get up too fast. Some patients have injuries that make one side weaker than the other.  Always try to compensate for the weak side.

Before the Lift

     Think about what you are doing.  Figure out the proper lifting technique for the task. Utilize the proper equipment, clear the area or path of hazards, and get help if you need it.  Gather the items you need before the lift or transfer. Never leave an “at-risk” person alone in a precarious position.

A special Note: Get Help

     You are not in this alone, and you are not superhuman. If the lifting is too heavy, get help, either from the proper equipment available or the assistance of someone else. Many hands always make the lifting easier and safer.

Know Your Patients

     Everyone has varying capabilities and weakness.  If you are new to the job, make it a priority to learn what disabilities your charges have. Don’t be surprised in the middle of a lift that a patient can’t do this or that function. Always be aware that patients can have bad days that reduce their capacities.

Proper Body Mechanics

     Every lifting job is different, but there are common elements to all proper lifts or patient transfers

1. Face the person or object and establish a solid base of support. Place your feet shoulder length apart on solid, slip-free ground.

2. Keep your back straight.

3. Bend at the knees and not the lower back as much as possible.

4. Hold the object as close to you as possible.

5. Tighten your stomach muscles when lifting.

6. Lift as much as you can with your legs.

7. Never twist when you lift. Make adjustments with you footing instead.

8. Push rather than pull when you can.

9. Maintain good communication in team lifts.

10. Lift with smooth efforts, no sudden jerking.

     Patients are not the only heavy things that you might be required to lift. A 25-pound bag of potatoes, flipping a mattress,  or moving furniture around can overstrain the back if improper body mechanics are used.

 Patient Transfers

     Moving a patient from one place to another is an essential required skill for any care- giver. But awkward positions, tight, in-home spaces, and unpredictable patient movements can make transferring a patient a dangerous task. Over the years, techniques have been developed that will enable you to the move the patient easily and safely.

Rolling a Patient in Bed

1. Insure that there is enough room to roll the patient in the direction that is needed. 

2. Have the patient bend the opposite knee in the direction you want to roll.

3. Cross the opposite arm you want to go and have the patient reach in that direction

4. Place your hands on the shoulder and hip area and gently push until the roll is complete. 

Setting the Patient on the Edge of the Bed From a Reclining Position

1.  Bring the patient to the edge of the bed. This may take leveraging from top to bottom a little at a time.  Avoid pulling heavy patients all at once.

2. Dangle both feet over the edge of the bed.

3. Put one arm under the patient’s shoulders and one arm over the hip, slightly lower down the leg.

 4. Start by pulling the lower half of the body over the edge of the bed and then utilizing the natural pull of gravity lift from the shoulders until the patient is upright.

Note: if the patient is so large that it puts you in an awkward position, you might have to divide the task into two steps. Legs first, then lift the shoulders.

Transferring From Sitting to Sitting. Pivot Transfer

1. Secure the transfer destination. If it is a wheelchair. place it against the bed. Lock the wheels. Remove or swing away the foot rests. Remove the arm of the chair that is against the bed, if required. 

2. Bring the patient to the edge of the thing they are sitting on (bed, chair, or car seat).

3. Utilize a transfer belt, if one is available.

4. Place your foot in front of the patient’s toes to prevent slipping.

5. Bend at your knees and reach around and grab on the patient belt.

6. Tell the patient you’re about to lift and count to three. If there is some difficulty, you can start a forward rocking motion on each count, one, two, and lift on three.

7. Have the patient push off with their hands or place their hands on your shoulders or upper arms, never around your neck.

8. Lift straight up utilizing the natural pull of your weight and lift from your legs. Tighten your stomach muscles to help take the strain off your lower back.  Never lift from your lower back muscles. 

9. Once the patient is standing and while you are still holding the belt, turn the entire body by taking small steps with your feet. Do not twist from the waist.

10. Gently support the downward movement of the body by bending your legs and keeping your back straight until the patient is safely seated. Keep the patient in your center of gravity by placing your feet on the outside of the patient’s feet and your knees on the outside of the patient’s knees.

Note: Position the destination chair on the strong side of the patient. Provide verbal cues for example, “turn, turn, OK, sit.” Positioning the receiving wheelchair at a slight 30-degree angle creates a bigger receiving “target” for the patient.   

Repositioning the Patient in a Chair

1.  Have the patient lean forward with their shoulders toward their knees.

2. Place yourself in front on the patient with knees against the knees of the patient.

3. Bend at your knees and grab hold of the patient’s belt (or transfer belt if it is needed).

4. On the count of three, roll your feet on to your toes and push with your knees against the patient’s knees, utilizing your own natural leverage to lift the patient’s bottom off the cushion.

5. Gently slide the patient forward into the desired position. Don’t lift the patient.

Sliding Board transfer

A transfer board is any sturdy board that is placed as a “bridge” between two positions and the patient slides to their destination.

1. Place the patient at the edge of the place they are sitting on. Lean the patient away from their destination.

2. Place one end of the board under the elevated hip. Be careful not to pinch the skin. Place the other end at the destination securely.

3. Have the patient “scoot” along the board with your guidance so they do not lose their balance and fall. Let the patient do the work or if necessary use several abbreviated pivot transfers.

Note: Utilize gravity by making the destination lower than the starting position if you can. Have the patient take advantage of any secure hand holds that are available. For difficult transfers like from a small car, an intermediate destination might be of use, utilizing two transfer boards.

Special Notes for Transferring the Patient to a Car

     Make sure the car seat is moved back as far as it can go. Recline the back of the seat slightly to provide more room. After the patient is in, you can straighten the seat into a more comfortable position. Roll the window down so that the car door can become a handhold. 

 

What To Do in Falls

 

     A patient falling is always a major concern. Unfortunately, it is almost inevitable with In Home care that a patient will end up on the floor.  Keep your ears tuned in. It is most likely you will hear a fall before you see one. Prompt action is required. Always inspect the area and the patient before taking any action.

     Lifting a patient from the floor is particularly dangerous for the patient and the caregiver. If the lift is not done right, the patient can suffer further injury and the caregiver can end up injured, too.

First: Prevent the Fall in the First Place

     As you walk with the patient, find the center of balance and place your hand there. For most, it is the lower back, conveniently close to the belt line.  Grab on the belt, if there is one.  If you need to, apply a transfer belt.  As you walk, feel for unusual movement and give balance when needed to keep the patient on their feet.

     Many falls happen when the patient tries to get up to fast. Do not pull the patient up from a relaxed position all at once. Set them up and tell them to get ready to stand up. Make sure they scoot their bottom to the edge, straighten up, firmly place their feet, and get their balance ready.

     Transfer boards are handy when going from sitting to sitting positions or standing to a difficult sitting place, for example, getting into a car or bath tub. Place a stool or chair outside the car or tub and place the transfer board between them. Have the patient sit on the transfer board and slide the patient to their destination.  

Second: During the Fall

     Usually you can keep a patient upright by helping to maintain balance, but there are times when that isn’t going to be adequate. Sometimes the patient is going down no matter what you do. Don’t let them take you down with them or jerk your back out of place as you try to assist them.

1. If the patient is falling, do not try to stop it. Control the fall instead.

2. Steer the fall to a safe place.

3. Slow the speed of the fall down from YOUR center of gravity, bending properly as you go down.  A safe way is to drop your center of gravity a little slower than the patient.

4. Protect the patient’s head.

5. Let the patient slide down your leg to the floor. Bend at the hips and knees as you

lower them.

 Third: After the fall

     If you were not present when the patient fell, first be sure the area is safe for you to go into. For example, be aware of electrical wires and broken glass hazards.  When a patient falls, most will want to get up right away. Don’t let them until you have made an injury assessment. 

Injury Assessment

1. Call the owner and 911 as per company policy when the patient has lost consciousness, has uncontrolled bleeding, stopped breathing, if the pupils are dilated inappropriately for the room lighting or if one pupil is larger than the other or any other life-threatening circumstance. If you feel overwhelmed, call the owner.

2.  Check for a sign of a fracture. The patient will report pain, tenderness. or hearing a pop or snap. You might notice swelling or bruising.

3. Hip fractures are of particular concern and are noticed by one leg being shorter than the other, there is an unusual angle to the leg, or the patient feels or hears a “crackling” when they move or they are unable to move. If a hip fracture is suspected, DO NOT move the patient. Make them comfortable and get help immediately, then keep them warm with a blanket.

4. Assess for signs of confusions or altered speech. Questions you can ask are:  What year is it?  Do you know where you are? Which room is yours? What were you trying to do before you fell?

5. Check for cuts and bleeding from head to toe. Skin tears look very severe but they are usually not life threatening. Head cuts have a tendency to bleed a lot, even minor ones.

6. If you suspect a head, neck, or spinal injury, DO NOT move the patient. Get help immediately.

When calling 911, be calm and communicate clearly. Note any pertinent details. It is better to give too much information than not enough. Always call the owner, too.

If There Are No Injuries

     If there are no injuries that you can see, help the patient get up in stages. There are several reasons for doing this. Unnoticed injuries will present themselves sooner and you can abort the attempt easier and safer.  It saves you from lifting the dead weight of the patient. It’s good for bruised egos and embarrassed patients to do the work themselves.  It makes them feel less of an invalid.

Stages from the floor

 1. Have the patient sit up.

 2. Turn the patient over until they are on their knees.

3. Have them lift one knee up.

 4. Lift patient to an upright position, utilizing proper body mechanics.  If needed, have a chair nearby and lift them to the seat first then stand them up. Do all these steps slowly with plenty of time for patient orientation in between.  

Note: patient transfer belts make the operation easy for you and safer for the patient.

 

Conclusion

 

     Do your patient, yourself, and your back a favor and be prepared before you lift or assist in transferring a patient. Know proper lifting techniques before you lift, think through the lift before you act, get the necessary equipment or help, use proper body lifting mechanics, communicate clearly, and lift with safety in mind. Remember, furniture and heavy supplies can be just as damaging to you as an improper patient lift.

     Helping others shouldn’t result in injuring yourself or the patient. Remember, you won’t be helping anyone if you find yourself on the wrong side of a back surgery.

Mark Parkinson RPh.

 

Resources

1.Guide lines for Nursing Homes,  Ergonomics for the Prevention of Musculoskeletal Disorders. OSHA

lhttp://www.premierinc.com/safety/topics/back_injury/downloads/Final_OSHA_Guidelines_nursing_homes.pdf

2.Transferring. University of Missouri- Kansas City

http://cas.umkc.edu/casww/transfrg.htm      

3. Back Injury Prevention. Premier Inc. com

http://www.premierinc.com/safety/topics/back_injury/

4. Ergonomics. OSHA, United States Dept. of Labor

http://www.osha.gov/SLTC/ergonomics/

5. Wirnani Garner, How to Do Proper Body Mechanics for Lifting. EHow Health.com

http://www.ehow.com/how_2302456_do-proper-body-mechanics-lifting.html

6. Em M. Pijl Zieber, Back care and Patient Transferring Techniques. LETHBRIDGE COMMUNITY COLLEGE

HEALTH & ALLIED WELLNESS. 2002 revised 2004

http://people.uleth.ca/~em.pijlzieber/BACK%20CARE%20LAB.pdf

7.  Melissa Sandoval, How to Use a Transfer Board to Move a Patient. EHow Health.com

http://www.ehow.com/how_5621732_use-transfer-board-move-patient.html

8. Transferring Using a Transfer Board, Krames Patient Education. Wishard

http://wishardhealth.kramesonline.com/HealthSheets/3,S,40382

 

Oh my ACHING Back! The Dangers of Lifting

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The Fungus Amongus

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1.5- Approximate time required: 90 min.

Educational Goal: 

To familiarize the In Home Care Giver with the concepts of fungal infections.

Educational Objectives:

1. Enumerate the prevalence of fungal infections and explain the reasons why it is so high.

2. Describe the signs and symptoms of fungal infections.

3. Explain how to prevent and treatment fungal outbreaks

4. Explain why relapse rates are so high and what to do about it.

5. How to overcome patient non-compliance issues.

Procedure:            

1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 

 

Disclaimer

  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

The Fungus Amongus

 

 Who Has the Fungus Amongus?

     There are a lot of nasty things that like to chew on us (besides tax collectors and ex-spouses, that is). Among the most prevalent is a group of fungi known as dermatophytes. You might know them better by their common names, athlete’s foot, jock itch, ring worn, and nail fungus.

     At any given time, more than 30 percent of the population can have fungi growing on them somewhere.  Athlete’s foot alone will infect more than 70 percent of all adults at least once in their lifetime.  In populations that have poor hygiene or compromised immune systems, the infection rate soars.  Since a majority of foster care clients comes from these groups, caregivers should be aware of and know how to deal with “The Fungus Amongus.” 

Why Is Fungus So Prevalent?

     Fungus is a group of organisms that is related to yeasts and molds.  They were here long before man came along and will be here long after we’re gone.  Fungi need only two things to survive - a carbon-based food source and water.  They can spread in two ways. They grow like plants, extending themselves along root like filaments called hyphae and they produce spores that are microscopic and can travel in the air.  Since they have been here a long, long time it’s safe to say that fungus and fungal spores can be found pretty much everywhere in our environment.

      Fungi come in a wide variety. The fungus that likes to grow on us is called Dermatophytes. As fungi, dermatophytes can survive just about anywhere, but they seem to thrive in warm, damp environments.  They don’t even need a human host to survive.  This makes fungal infections very contagious. All it takes is for the skin to come in contact with a source of a fungus and that person can become infected. Once infected, that person is now a fungal source and they can spread it to any other surface they come in contact with where the conditions are right for growth. Unfortunately for most humans, hot sweaty feet are ideal conditions for fungus to grow, especially between the two smallest toes.  

      It is now easy for you to understand that the highest risk areas for the spread of dermatophytes are warm, damp communal areas like gym showers, bathrooms, and pools - plenty of moist surfaces and lots of skin to come in contact with contaminated areas. And the highest prevalence for athlete’s food is found in young to middle-age men.

 

 

You Can Be Fungus-Free

     Regardless of the source or the prevalence, healthcare providers can identify and eliminate fungus from their homes.  It can be done in two phases. First, the home: Professional cleaners say that you usually don’t have a fungus problem, you actually have a moisture problem. First, if you can control how much moisture there is, you can control how much fungus there is.  Second, the infected person: antifungal medications and moisture control usually do the trick.  Being fungus free is mostly about timely action and knowing what to do.

     Luckily, fungal infections are not life threatening. For most, they just result in a chronic itch and stinging pain when the skin cracks. Complications can arise when secondary infections take advantage of the weakened skin area. Due to this and its contagious nature, care providers must learn to screen for and treat fungal infections quickly and effectively. If you know what you’re doing, fungus is easily identified and eradicated. Of course, the first place to start is with yourself and your home then move on to your current residents. After your home is fungus free, all you have to do is carefully screen new move-ins. Your home can be free from fungal infections

 

Signs and Symptoms

 

     To get rid of the fungus amongus, caregivers must know what to look for and where to find it. First, let’s all get on the same page.

Medical Language

     In medical terms, skin fungi are dermatophytes. The three main infectious types are trichophyton, epidermophyton, and microsporum. Dermatophytic infections of the skin can manifest themselves anywhere on the body. Infections are named by the beginning term “tinea” and the ending term dependent on the area of involvement. Thus tinea capitis affects the scalp, tinea barbae- the face, tinea unguum- the nails, tinea manuum- the hands, tinea cruris- the groin area (jock itch), and tinea pedis is the feet (athlete’s foot). But outside of understanding medical literature and other health professionals, who cares what the Latin name is? What really matters is what it looks like. What is the physical appearance of a fungal infection?  To know what you’re looking for, you have to understand what is going on in the affected area.  

 

Anatomy

 

     The skin is the largest organ of your body and is composed of multiple layers of tissue. The two main groups are the dermis and epidermis.   The epidermis is the skin’s outermost layer. It is made up of skin cells that provide protection for the inner skin layers.  Basal cells at the bottom of the epidermis reproduce and move the new skin cells outward thus replacing the outermost cells that wear off. 

     When an infection occurs, dermatophytes invade and start to grow under the top most layers of the epidermis skin cells. The basal cells respond by overproducing cells trying to slough off the infection.  As the excess cells reach the skin’s surface, they cause the first visible appearance of a fungal infection. (Understanding this will become important in treatment. More about that later.) If the infection gets bad enough, the body’s immune system senses the infection and tries to contain and stop it by inflammation, sensitivity, and other immune responses. That sensitivity is most often felt as an itching sensation alerting us to the presence of an active infection.

 

The Different Varieties

     Now that we have covered the basics and are all on the same page, let us review what some of the most common fungal infections look like. Starting from the top:

 

Tinea Capitis  (cradle cap)

     Not all flaky dandruff is from a dry scalp.  If you encounter a bad case of dandruff that just won’t go away with dandruff treatment, talk to the doctor about the possibility of fungus. More pronounced infections can appear as round bald patches with tiny black dots that are actually hair shafts that have broken off.  Patches can appear scaly and can also be red or swollen with puss-filled sores.   The scalp is usually itchy.

 

Dermatophytosis (ringworm)

     Ringworm, of course, is not a worm at all but it does look like there is one under the skin.  Infections are itchy and have red, raised, scaly patches that may blister and ooze. The patches have sharply-defined edges. Red patches are often redder around the outside with normal skin tone in the center. This may look like a ring. And just in case you are wondering, you can catch ringworm from handling infected pets.

 

Tinea Curuis (jock itch)

     Jock itch (or any folds of the body like under the breast, anus, or fat folds) is basically ring worm.  The signs are itching in the fold of the skin, red, raised, scaly patches that may blister and ooze. The patches usually are redder on the outside with sharply defined edges, abnormally light or dark skin and patches can have a bad smell.

 

Tinea Pedis (athlete’s foot)

     The classic signs of athlete’s foot are itchy flaky or peeling skin, most often accompanied by bad odor.   There are three main types of athlete’s foot. The most common is interdigital tinea pedis or fungus in between the toes. In this type of infection, the skin within the toe web will appear as inflamed, scaly, and with soggy white tissue.  Splitting of the skin, called fissures, may be present between or under the toes.   Hypereratotic or moccasin-type infection is a more prolonged infection that covers the soles and lower sides of the foot (where a moccasin would cover). The skin appears darker, scaly, flaky, reddened, and slightly thicker. The least common form is called acute vesicular tinea pedis, where fluid-filled cysts or blisters (vesicles) form, pop, and create open sores. The inflammation is usually quite itchy.

Tinea unguium or Onychomycosis (nail fungus)

     Dermatophytes can get under and even in the nails of the hand and foot.  Typically, the nail thickens and a white, yellow, or brown discoloration occurs. Occasionally, pitting and small fissures are present. Sometimes the nails get so thick that it interferes with walking and shoe apparel.  Toe nail fungus is a long-term problem. It is very difficult to treat. It can also act as a repository for the dermatophytes that can continually re-infect the surrounding skin.  A podiatrist (foot doctor) is another option for treatment and is better equipped to handle thickened nails.

Look-Alike Conditions.

     There are other conditions that can mimic fungal infections. Maladies like eczema, seborrhea, and localized allergic reactions have been mistakenly identified as fungal outbreaks. Fortunately, you as a caregiver don’t have to tell them apart. You are just screening for the possibility of infection and the doctor will do the diagnosis.  The guiding principle is “when in doubt send them out,” to the doctor, that is. 

Complications

     Life is never as simple as black and white. The same is true with fungal infections. Complications can arise that may need attention.  The most common complication  is odor. As the fungus spreads, the skin is compromised, leaving an opening for bacteria to grow. Signs of a bacterial infection are swelling, red streaks, and pain. The body can fight off these infections by itself, but those with weakened immune systems may need antibiotic help. These secondary infections can produce very unpleasant odors. Controlling the bacteria is the key to controlling the odor. For those with compromised immune systems like diabetics, uncontrolled fungal infections can be the first step toward amputations.

     Two less common but nevertheless serious complications are the ID reaction and asthmatic attacks.  The ID reaction or dermatophytid is in basic terms a localized allergic reaction to the fungus. It is typically seen as a generalized, diffuse rash. It might look very nasty but the condition will go away by itself when the infection is cured. There have been some reports of increased asthma attacks when fungal infections are present. It would be wise to keep a rescue inhaler handy when treating fungus. 

 

Treatments

 

Now let’s talk about how to get rid of the Fungus Amongus

Prevention

     Prevention is always the best cure. Fungus needs a wet environment to thrive and direct contact to the skin to spread. If you can control these two conditions, you can pretty much keep you home fungal infection free.  Good hygiene techniques are your best bet at prevention.

Bathrooms

     Bathrooms and showers are always damp and can be hard to maintain a surface free of fungus.  Molds also grow in the same conditions as fungus, so if you see mold, there is a good chance that fungus is there also. Here are a few cleaning tips:

  • Increase ventilation by running a fan or opening a window.
  • Wipe down bath tubs and showers and keep plumbing in good repair. 
  • Porous or absorbent material may have to be thrown away if they become moldy.
  • Don’t paint or caulk over moldy corners.
  • Choose cleaning products that say they are disinfectant cleaners. Cleaning an area by itself will not kill all the fungus, and disinfecting an area without cleaning also leaves behind hiding places for the fungus to grow back.  You can use separate products but choosing a disinfectant cleaner is more efficient use of your time. It is important to leave the disinfectant on the surface for about 10 minutes so that it can penetrate the surface and kill the fungus.
  • While treating a fungal infection, clean surfaces more often.

Laundry

     Towels, wash rags, socks, and clothing can be a source for the spread of the fungus amongus.  Bleach kills fungus, also the “Hot” settings on you laundry machines kills as well. Keep you dryer vents clear and your dryer will run hotter. 

Shoes

     It’s hard to wash shoes, but let’s face it, they need it from time to time.  Bacteria can really make them stink.  What good is it to treat the infection if you continually put the same infected shoes on.  A few cleaning tips for shoes (and slippers).

  • You can purchase special disinfecting shoe insert machines. One idea is to let the business buy the machine and rent it to those with a problem. It could pay for itself or even be a source of income.
  • Treat shoes with antifungal powders.
  • Pour rubbing alcohol onto shoes and let stand for five minutes. This will kill the bacteria, too.   (It could also ruin shoes- be careful.)
  • If you’re desperate or the above is impractical, place the shoes into an airtight plastic bag and put them in the freezer overnight. That will kill the fungus amongus and eliminate odor-causing bacteria.
  • If you have sweaty feet, you may have to buy ventilated shoes.

Feet

     Keep feet dry. Dry in between the toes after bathing. Don’t share towels. It might also be a good idea to have a separate towels for infected areas to keep the infection from spreading to different parts of the body. Change socks often.  Flip flops or shower shoes are also be a good idea, especially in communal areas that are not under your control.

 

Cures

 

Non-Pharmacological Treatment

     Even with your best effort sometimes an infection will slip past your prevention efforts, or you have a new client move in with an active infection.  It is good to note that (depending on the severity of the case and hygiene efforts of the patient) about 30-40 percent of infections can resolve themselves. There is a lot of anecdotal evidence that changing the pH [p(H)] can kill off fungus. So, home remedies like soaking your feet in vinegar, baking soda, boric acid, or bleach might or might not help. You can try these on yourself but you cannot use them on your resident without a doctor’s permission. 

Pharmacological Treatment

     Most infections respond well to topical antifungal agents. For severe or topical treatment failure, oral medications may be needed.  In addition, depriving the infection of moisture through the use of a dry powder or zinc oxide-based diaper rash cream may be a good add-on treatment. For scalp infection, there are antifungal shampoos.

     In cases where there is significant pain and rash, the doctor might use a topical steroid in addition to an antifungal or in a combination steroid/antifungal product.  You should know as a caregiver that applying topical treatments to fissures and open sores are going to sting. 

     One note of interest, fungi are complicated structure that are not easily mutated. Therefore you don’t see much medication-resistant strains developing. 

 

 

More Medical Terminology

     In considering treatments, it is important to understand the difference between the terms fungistatic and fungicidal.  Fungistatic means to halt the progression or growth of the organism. Fungicidal means to kill it off. You can probably guess that a fungistatic agent take longer to eradicate the outbreak. 

Topical (on top of the skin)

     Topical agents are the first-line therapy for most doctors. They are safe, easy-to-use, and inexpensive. In clinical trials, fungicidal agents are the most effective while undecyline acid is the least effective.

 

Table 1. Nonprescription Antifungal Products

Agent

Brand Names

Formulations

Dosing

Minimum
Effective
Duration

Comments

Azole

   clotrimazole 1%

Desenex®

Lotrimin® AF

cream, lotion,

powder,

solution,

spray solution

BID

4

fungistatic

   ketoconazole 2%

EXTINA®

Nizoral®

Cream

 

1% Shampoo*

BID

6

fungistatic

   miconazole 2%

Desenex®,

Lotrimin® AF,

Micatin®,

Micozole,

Monistat®

cream, lotion,

gel, powder ,

spray

powder,

spray

solution

BID

4

fungistatic

   tolnaftate 1%

Lamisil AF

Defense,

Tinactin®

cream,

powder,

spray powder,

spray solution,

solution

BID

4

fungistatic

   undecylenic acid

 

5% to 25%

BID

4

fungistatic

   5% to 25%

Desenex®

cream,

powder,

powder spray,

liquid

 

 

 

Allylamines

   terbinafine

   1%

Lamisil AT®

cream,

spray solution,

gel

QD

1

fungicidal

Benzylamines

   butenafine

   1%

Lotrimin®

Ultra

cream

BID for
1 week,
then QD
for 4
weeks

5

fungicidal

 

* Shampoo is dosed differently, see container for proper use.

 

 

Table 2. Prescription Products for the Treatment of Tinea Pedis

Agent

Brand Names

Formulation

Dosing

Minimum
Effective
Duration

Comments

Azoles

   econazole 1%

Spectazole®

cream

QD

4

fungistatic

   oxiconazole 1%

Oxistat®

cream,
lotion

QD or BID

4

fungistatic

   sertaconazole 2%

ERTACZO®

cream

BID

4

fungistatic

   sulconazole 1%

Exelderm®

solution

BID

4

fungistatic

   itraconazole 200 mga

SPORANOX®

capsules,

oral

solution,

injection

QD-BID

1-4b

fungistatic

   fluconazole

   50 to100 mg

DIFLUCAN®

Tablets,
injection for
intravenous
infusion
only, oral
suspension

QD

4-6b

fungistatic

Allylamines

   naftifine 1%

NAFTIN®

cream,

gel

QD‐BID

4

fungistatic

   terbinafine 250 mga

LAMISIL®

tablets

QD po

2b

fungistatic
the most
effective
oral agent

Others

   ciclopirox 0.77%

Loprox®

Cream, gel,

lotion,

shampoo

BID

4

fungistatic

 

aNot FDA-approved for the treatment of Tinea pedis.

Source of tables 1 and 2: Gina J. Ryan PharmD, BCPS, CDE, Fostering Patient Adherence in the Management of Tinea Pedis

Oral Medications

     There are times when topical therapy is not enough. The doctor may choose to use or add on an antifungal oral medication. Itraconazole, terbinafine, and fluconazole come as oral tablets.

Tea Tree Oil

     There are many antifungal products that contain tea tree oil. Despite some reports, tea tree oil does not kill fungus. It is believed to help by instantly reliving the itch. Without the constant scratching, wounds heal faster by themselves.

 

Preventing Recurrence

 

     There is a high relapse rate for fungal infections.   As many as 70 to 80 percent of cases relapse. In my opinion, the two major reasons for this are poor hygiene and incomplete eradication of the existing fungal infection. Let me explain further.

 

     Remember that fungus invades under the skin.  The body tries to slough it off by over producing skin cells. That is the visual signs of infection. Most uninformed patients will treat the infection until all visible signs are gone. Unfortunately for those patients, there is still a full-blown infection going on that they can’t see.  So, in essence, they never really cure themselves in the first place and the infection comes roaring back.

 

 The key to preventing recurrence is proper education and regular inspections.

 Teach proper hygiene techniques to your staff, family, and clients.

Reinforce and reward good efforts.

Tell patients about how they might still be infected and to continue therapy long after all visible signs of the fungus amongus are gone.

The rule of thumb is fungistatic meds require two-four additional weeks and fungicidal treatments require one week after all visible signs are gone. 

Regular inspection of the home and patient is just good patient care.

 

     If despite your best efforts the infections keep coming back, then most likely the patient is getting re-infected from an outside source. Check for pets or neighborhood animals with balding spots (possibly an active fungal infection). Look for moldy spots in their environment. If you can’t identify or illuminate the source, you may have to use antifungal powders on a continual basis as a preventative measure. Getting a PRN order from the doctor would do the trick.

 

Noncompliance Issue

     One more piece of patient information for you. If there is an open fissure or wound, antifungal treatments will sting - sometimes a lot. Warn your patients beforehand and inform them that the sting will go away as the body heals. If noncompliance because of pain becomes an issue, you might ask the doctor for a topical steroid cream or tea tree oil.  

 

Conclusion

 

     The fungus amongus may be common in the general population, but it doesn’t have to be prevalent in your home. With proper hygiene and patient care technique, you can completely eliminate it from your home. In the end, it will be one less thing for you to worry about.

Good luck in your efforts.

 

 

References:

1. What is a Dermatologist?, Consumers' Research Council of America.

http://www.consumersresearchcncl.org/Healthcare/Dermatologists/derma_chapter1.html

2. Gina J. Ryan PharmD, BCPS, CDE. Michael Cantrell, DPM. Fostering Patient Adherence in the Management of Tinea Pedis, Apr 10. 2010. Power-pakCE. 

http://www.powerpak.com/course/preamble/106739

3. Athlete’s Foot. Health Spot.

http://www.ihealthspot.com/Home/PatientEducation/FamilyPractice/tabid/10431/ctl/View/mid/17218/Default.aspx?ContentPubID=940

4. Athlete’s Foot. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Athlete's_foot

5. Guha Krishnaswamy, James H. Quillen. Dermatology for the practicing allergist: Tinea pedis and its complications.  Mar.29,2004. Clinical and Molecular Allergy.

http://www.clinicalmolecularallergy.com/content/2/1/5

6. Jock Itch. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001879/

7. Onychomycosis. Wikipedia The Free Encyclopedia.

http://en.wikipedia.org/wiki/Onychomycosis

8. Tinea Capitis. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001881/

9. Ringworm. PubMed Health, U.S. National Library of Medicine.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002411/

10. Athlete’s Foot (Tinea Pedis). Our Health Network.Com

http://www.ourhealthnetwork.com/conditions/FootandAnkle/AthletesFoot.asp

11. Epidermis. Wikipedia The Free Encyclopedia.                           

http://en.wikipedia.org/wiki/Epidermis_(skin)

12. A Brief Guide to Mold, Moisture, and Your Home. U.S. Environmental Agency.

http://www.epa.gov/mold/cleanupguidelines.html

13. How to Disinfect Used Shoes. WikiHow.com.

http://www.wikihow.com/Disinfect-Used-Shoes

14. Tisha Tolar. How to Disinfect Showers for Athlete's Foot. eHOW.com.

http://www.ehow.com/how_5681103_disinfect-showers-athlete_s-foot.html

15.  Mary Marlowe Leverette. How to Prevent Spread of Athlete's Foot in Laundry. About.com

http://laundry.about.com/od/laundrybasics/a/athletesfootlaundry.htm

16.  Ivan Bristow, Manfred Mak. Fungal foot infection: the hidden enemy?  Wounds uk, 2009, Vol 5, No 4

http://www.woundsinternational.com/pdf/content_9316.pdf

 

 The Fungus Amongus

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