PHAR155 final lectures
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| Define motivational interviewing | A patient-centered, directive method for motivating change by exploring and resolving ambivalance and resistance
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| 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
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| Traditional model of patient communication vs motivational interviewing model of communication | Focus on illness vs focus on wellness
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| Four key motivational interviewing skills | 1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support self-efficacy
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| Motivational interviewing tools | Rulers, envelope, a look over the fence
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| Four health behaviors that contribute to a longer life | Not smoking, eating a healthy diet, getting regular physical activity, limiting alcohol consumption
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| Transtheoretical model and stages of change | Precontemplation, contemplation, preparation, action, maintenance
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| Express empathy | Be aware, sensitive, respectful of where someone is coming from to appreciate a person's experience/situation. Need non-judgmental, reflective listening
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| Reflective listening | Listen actively, decide if understood message, reflect in own words, invite further sharing. Never use "I understand"
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| Simple vs complex reflective listening | Simple: repeating, rephrasing. Complex: paraphrasing, reflection of feeling
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| 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
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| Roll with resistance | Resistance is not directly opposed, is a signal to respond differently
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| Support self-efficacy | Promote self-confidence & ability to overcome current problems and create successful change. Pt is responsible for choosing and carrying out change.
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| 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)?
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| 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)?"
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| 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 ___?"
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| 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
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| 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
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| 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.
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| 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.
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| Describe counseling recommendations related to tobacco cessation | Abstinence. Past quit experiences? Anticipate triggers. Avoid alcohol. Other smokers? Assess confidence/importance.
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| 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
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| 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.
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| 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.
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| The 5 R's for patient to state who are in the 'unwilling to quit' bucket (#4) | RELEVANCE, RISKS, REWARDS, ROADBLOCKS, REPETITION
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| 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
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| Encourage medications for all willing to quit unless: | contraindicated, pregnant, smokeless tobacco users, light smokers (<10 cigarettes/day), adolescents
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| First-Line Smoking Cessation medications | NRT, bupropion SR, varenicline
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| 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,
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| 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
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| Varenicline patient counseling | Chantix-prescription only. DAY 8=QUIT DATE. BBW=neuropsychiatric events. Nausea. Can't combine with NRT.
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| 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)
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| Compare med regimen review and med therapy mgmt services | MMR is one of 5 components of MTM services provided
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| 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
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| 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
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| Prospective MRR | point of admin, arrival, or initiation. for drug or disease interactions, dosing, appropriate selection, duplication, cost issues
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| Concurrent MMR | while med therapy is ongoing. for ADR, changing condition, unnecessary med, adherence, monitoring
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| Retrospective MMR | after med D/C or after discharge. for CQI, peer review
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| Examples of MRR processes | DTP, medication appropriateness index, ASCP MRR checklist, pharmacotherapy workup, I ESCAPED CPR mneumonic
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| 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
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| 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
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| 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.
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| 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"
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