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IPSA Final lectures

PHAR155 final lectures

Define motivational interviewing A patient-centered, directive method for motivating change by exploring and resolving ambivalance and resistance
How can motivational interviewing be used in patient interactions? Have caring, collaborative approach. Speak less, listen more, speak simply. Allow pt to generate own ideas. Ask permission to give expert advice. Balance open-ended questions with reflections
Traditional model of patient communication vs motivational interviewing model of communication Focus on illness vs focus on wellness
Four key motivational interviewing skills 1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support self-efficacy
Motivational interviewing tools Rulers, envelope, a look over the fence
Four health behaviors that contribute to a longer life Not smoking, eating a healthy diet, getting regular physical activity, limiting alcohol consumption
Transtheoretical model and stages of change Precontemplation, contemplation, preparation, action, maintenance
Express empathy Be aware, sensitive, respectful of where someone is coming from to appreciate a person's experience/situation. Need non-judgmental, reflective listening
Reflective listening Listen actively, decide if understood message, reflect in own words, invite further sharing. Never use "I understand"
Simple vs complex reflective listening Simple: repeating, rephrasing. Complex: paraphrasing, reflection of feeling
Develop discrepancy Discrepancy: quality or state of disagreeing or being at variance. Change motivated by perceived discrepancy b/w present behavior and important personal goals or values
Roll with resistance Resistance is not directly opposed, is a signal to respond differently
Support self-efficacy Promote self-confidence & ability to overcome current problems and create successful change. Pt is responsible for choosing and carrying out change.
Motivational tool: the ruler 1. On scale of 0-10 (define #s), how willing/confidient are you to change __ at this time? 2. Why a __ and not a (lower number)? 3. What would it take to get you at a (higher number)?
Motivational tool: the envelope "If i were to hand you an envelope, what would the message inside have to say for you to (carry out the change)?"
Motivational tool: a look over the fence "If you were to take a look over a fence at yourself in (#) years...what would you like to see with regards to ___?"
Describe the purposes of presenting patient case information Present a new patient to preceptor or rounds, request consultant's advice on clinical problem, persuade others about diagnosis or treatment plan, use as tool for assessing clinical competence
Differentiate among what information is presented in the various sections of the patient case template CC, HPI, PMH (include surgical history), pertinent SH and FH, medication history, allergies, ROS, PE, pertinent lab data, SUMMARIZE ABOVE INFORMATION, assessment, plan
Describe key recommendations of PHS "treating tobacco use and dependence" guideline Chronic disease. Require repeated interventions & multiple quit attempts. Tx increases quit rates. Identify & document tobacco status. Offer brief treatment(5As), treat every user willing to quit, counseling works and increases with intensity.
Implement the 5As process ASK if he/she uses tobacco. ADVISE all users to quit. ASSESS willingness to quit at this time. ASSIST in making a quit attempt. ARRANGE follow-up.
Describe counseling recommendations related to tobacco cessation Abstinence. Past quit experiences? Anticipate triggers. Avoid alcohol. Other smokers? Assess confidence/importance.
Additional PHS key recommendations for smoking cessation counseling is practical and social. Meds encouraged for all patients. 7 1st-line meds available. Use BOTH meds and counseling. Provide motivational interviewing if unwilling to quit. Insurance should cover counseling and medications
Assess portion of smoking cessation: 4 buckets Not smoking now-never smoked. Not smoking now-once smoked. Smoking now-willing to quit. Smoking now-not willing to quit.
Assisting bucket #3 patients: STAR SET a quit date (within 2 weeks). TELL-ask for help. ANTICIPATE challenges (focus on first 2 weeks). REMOVE tobacco products.
The 5 R's for patient to state who are in the 'unwilling to quit' bucket (#4) RELEVANCE, RISKS, REWARDS, ROADBLOCKS, REPETITION
ARRANGE step for patients in bucket #3 Arrange follow-up in person or by phone within 1st week of quit date, then within first month, then prn. Review benefits, identify problems/successes, assess med issues, review situation and recommit if relapse occurs
Encourage medications for all willing to quit unless: contraindicated, pregnant, smokeless tobacco users, light smokers (<10 cigarettes/day), adolescents
First-Line Smoking Cessation medications NRT, bupropion SR, varenicline
NRT patient counseling Monitor BP and pulse, preg D, quit smoking, schedule not prn, no food/acid beverages 15 mn or during use of buccal absorption methods, "chew and park" method for gum,
Bupropion SR patient counseling Zyban-prescription only. Begin at least 1 week prior to quit date, with the quit date during week 2. BBW neuropsychiatric events. Can combine with NRT. AE: insomnia
Varenicline patient counseling Chantix-prescription only. DAY 8=QUIT DATE. BBW=neuropsychiatric events. Nausea. Can't combine with NRT.
Differentiate b/w patient-specific and population-based med regimen reviews Patient-specific: evaluate individual regimen and maximize benefit of therapy vs potential risks Population-based: pattern of care, quality indicators (medication-based or care-based)
Compare med regimen review and med therapy mgmt services MMR is one of 5 components of MTM services provided
Describe processes utilized to conduct med regimen reviews 1) Collect patient-specific info. 2) assess med therapies to identify DTP 3) develop prioritized list of DTPs 4) create resolution plan
Define MRR (DRR) promote + outcomes and minimize adverse consequences. prevent, identify, report, and resolve med-related problems/errors/etc. collaborate w/ other members of the team
Prospective MRR point of admin, arrival, or initiation. for drug or disease interactions, dosing, appropriate selection, duplication, cost issues
Concurrent MMR while med therapy is ongoing. for ADR, changing condition, unnecessary med, adherence, monitoring
Retrospective MMR after med D/C or after discharge. for CQI, peer review
Examples of MRR processes DTP, medication appropriateness index, ASCP MRR checklist, pharmacotherapy workup, I ESCAPED CPR mneumonic
Proper steps for insulin injection technique 1. Gather & organize supplies. 2. Wash hands and site.Rotate injection site area. 3. Inspect insulin vial or pen 4. Gently roll cloudy insulin in palms 5. Prepare vial/pen 6. Inject insulin, hold for 10 sec
Proper method for mixing insulin 1. Inject air to CLOUDY insulin, then into clear 2. Draw up CLEAR insulin first (inspect syringe) 3. Draw up CLOUDY insulin second
Patient counseling to address patient concerns with injecting insulin Shorter needle reduce risk of injecting into muscle. Never reuse needle as this dulls it and causes pain. Store insulin at RT. Let alcohol dry before injecting.
Tips for selecting injection site for insulin stomach: >2in from belly button or scars. Thigh: >4 in (hand's width) above knee ad below top of leg. Don't inject into inner thigh. Arm: fatty tissue on back of arm. Buttock: into hip or "wallet area"
Created by: steponmegrace