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Cocaine (and crack) impairs the immune defence against infections by inhibiting neutrophils and macrophages (Baldwin et al menopause quotes buy discount menosan line. In particular women's health center in salisbury md purchase menosan cheap, the smoking of crack and the intravenous use of cocaine are associated with high-risk sexual practices menopause foods buy menosan 60 caps visa. Chronic base cocaine use can lead to menstrual headaches symptoms buy discount menosan 60caps line over-fatigue and weight loss, leading to complete exhaustion. This depletion in combination with the ‘crash’ of cocaine users may lead to irritable, sad, aggressive or paranoid conditions. However, lifetime-risk increase has been reported in recent prospective studies to be much lower, with an average risk increase (over non-users) of about 6% (Amin et al. Regarding a non-fatal myocardial infarction, the population attributable fraction of cocaine use was 0. According to Jellinek Clinic one out of four non-fatal heart attacks in men aged <45 years is related to cocaine use. The acute respiratory complaints include cough with sputum production, chest pain with or without shortness of breath, haemoptysis and exacerbation of asthma. It has been suggested that there is a connection between binge use and transmission risk. Most crack smokers use in binge cycles; that is, users rarely stop with one hit, but use as much crack as resources allow, and then ‘‘crash’’ into a state of physical and psychological withdrawal (Harzke et al. The reason may be the high prevalence of unprotected sex, having multiple partners, and exchange sex for drugs or money. In several studies, prevalence rates of 20-30% have been reported in Europe and 16-65% in the United States (Ruiz and Strain, 2011). In a prospective study among drug injectors in Amsterdam, the incidence of abscess was 33 per 100 person-years. Skin and soft tissue infections may progress to systemic infections including endocarditis. Most fatalities associated with cocaine use are caused by cardiovascular or cerebrovascular accidents. Therefore, chronic cocaine use may be overlooked as the cause of death and reported death rates likely underestimate the real death rate by cocaine. Approximately 5% to 10% of emergency department visits in the United States is believed to be secondary to cocaine usage, leading to the evaluation of approximately 64,000 patients annually for possible myocardial infarction, of which approximately 57% are admitted to the hospital, resulting in an annual cost exceeding 60 million (Maraj et al. Overindulgence will produce early symptoms of alcohol intoxication, like nausea and vomiting, which urges most people to temporarily stop drinking alcohol. Headache (hang-over), impaired sexual capability and temporary loss of memory are typical symptoms of high alcohol consumption and intoxication. The consumption of high amounts of alcohol (blood alcohol concentrations >400 mg/dl; 4‰) produces loss of consciousness, and can be dangerous or even prove lethal due to respiratory depression and coma. Moreover, due to the diminished reaction time and impaired locomotor activity, alcohol intoxicated subjects are more liable to sometimes fatal traffic accidents and injuries. In alcoholics, the risk of death by suicide, homicide, fire, and drowning is roughly doubled. In Europe, alcohol is involved in 40% of murders and manslaughters, and in 16% of suicides (Anderson and Baumberg, 2006). World-wide, approximately 125 million people are affected by alcohol-use disorders and many more people suffer from alcohol use disorders than from illicit drug use disorders. Annually, alcohol kills 35 people per every 100,000, whereas for illicit drugs this is nine times less. Proportions attributable to alcohol use for major alcohol related diseases and injuries (Room et al. This explains why the population level social harm scores for legal drugs are generally higher than individual level social harm scores (and thus the total harm score), whereas the opposite is generally true for illicit drugs (cf. In 2006, the epidemiological studies on long term effects of alcohol consumption have been reviewed by the Dutch Health Council (Health Council of the Netherlands, 2006) and parts are used in the present review. The few cohort studies conducted among women all confirm the protective effects of alcohol at consumption levels below a rather high (see below) cut-off level of 48 g/day (Fuchs et al. However, it has been suggested that the cardiac protection caused by alcohol is overestimated in prospective epidemiological mortality studies, because of contamination of the abstainer category with occasional or former drinkers (Filmore et al. Indeed, the harm of alcohol consumption is many times higher than its protective effects, considering that consumption of alcohol is related to over 60 medical conditions. This is confirmed by the data depicted in Table 12, which reflect the proportions attributable to excessive alcohol use for major alcohol related diseases and injuries. Non-drinkers have higher all-cause mortality than light and moderate drinkers, and heavy drinkers have even higher all-cause mortality than either group. A meta-analysis, published in 1996, of 16 cohort studies on alcohol consumption and all-cause mortality confirms the J-shape curve (Holman et al. An important prospective cohort study not yet included in the latter review nor in the meta-analysis, was the study by Thun et al. The analyses were adjusted for many potential confounders, including education and smoking. For men as well as women, total mortality appeared to be lowest at a consumption of one alcoholic drink per day (12 g/day), but in women the rate of increase of the risk at a higher consumption level was larger than in men. In addition, alcohol induces lesions of the oesophagus and duodenum and is also an aetiological factor in acute and chronic pancreatitis (Rall, 1992). In humans, the most critical and dominant non-carcinogenic effect induced by alcohol overconsumption appears to be liver cirrhosis. Reversible conditions, such as steatosis (fatty liver) and alcoholic hepatitis, precede the occurrence of irreversible cirrhosis and are presumably causally related to it (Sorensen et al. A consumption of 12 g of alcohol per day did not seem to increase the risk of liver cirrhosis to a very large extent, but above that level, an increase of the risk was apparent. Typically, cirrhosis requires the consumption of at least 80 g of alcohol daily for 10-20 years (Lelbach, 1975). Pancreatitis, both acute and chronic, is another complication of excessive alcohol consumption; it ranges from an uneasy but stable condition to a medical emergency, depending on the severity of the event. The development of type I diabetes is rare and due to almost complete destruction of the pancreas. Thyroid disease can also result in excessive alcohol consumption, drug abuse or dependence (Johnson and Marzani-Nissen, 2010). Alcohol can also exacerbate hepatitis C infection, considering that more than half of all patients with hepatitis C have a past history of alcohol use, and chronic alcohol consumption (Safdar and Schiff, 2004). Individuals that consume more than five drinks per day with hepatitis C show an increase in the rate of liver fibrosis, cirrhosis, hepatocellular carcinoma and, possibly, death from liver disease (Jamal et al. The use of alcohol also seems to mitigate certain autoimmune diseases, like systemic lupus erythematosus and rheumatoid arthritis. Whatever the cause, the incidence of cardiac arrhythmia doubles for heavy drinkers compared with light drinkers (Cohen et al. The incidence of cardiac arrhythmias following alcohol consumption is commonly known as ‘holiday heart phenomenon’. Alcohol use leads to hypertension as a causal relation exists between the use of >30-60 g/day and blood pressure elevation in men and women (Grobbee et al. Assuming a linear relationship with no threshold, an additional drink a day (10 g) would increase both systolic and diastolic blood pressures by 1 2 mmHg (Anderson et al. Though most epidemiological studies suggest that regular light to moderate alcohol intake (16-32 g/day) probably reduces the risk of ischaemic stroke, regular consumption of more than 40 g of alcohol per day and binge drinking increases the risk of ischaemic and haemorrhagic stroke (due to cerebral or subarachnoid haemorrhage) (Anderson et al. Renal cell cancer, and non-Hodgkin’s lymphoma show much weaker, and less consistent associations with alcohol consumption (Baan et al. A meta-analysis of 27 studies (follow-up and case-control studies) (Longnecker et al. Later reports showed similar effect sizes, though at higher daily alcohol consumption (Cho et al. They also observed an almost linear dose-response association, but estimated a (confounder-adjusted) slightly lower increased risk of 7. As such, it has been suggested that alcohol may act as co-carcinogen by enhancing the carcinogenic effects of tobacco smoking (Blot et al. Note that an elevated mean corpuscular volume may also result from liver disease in the lipid bilayers that red cells do not form properly. When liver disease is severe, platelets may be destroyed or can isolate an enlarged spleen. Microcytic anaemias are associated with active bleeding or bleeding and the evaluation should ask for a gastrointestinal disorder or injury.

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May arise from tissue inflammation breast cancer 6s buy 60 caps menosan mastercard, mechanical deformation weird women's health issues generic 60caps menosan amex, ongoing injury menstrual like cramps at 38 weeks buy 60caps menosan with visa, or destruction women's health for over 50 generic 60 caps menosan with visa. One of the 4 following Pain Rating Scales (or other evidence based rating scales as they become available) shall be used as appropriate for the individual resident: 1. A Pain Rating Scale shall be completed and documented, at a minimum, in the following circumstances: 1. If the patient/resident is cognitively impaired or non-verbal, the facility shall utilize pain rating scales for the cognitively impaired and non-verbal resident. In skilled nursing facilities, a complete Pain Assessment shall be completed at admission, if pain is identified, an assessment must be completed on every shift. In assisted living communities, the evaluations/assessments are completed at a frequency required by state regulations and shall include a pain rating scale appropriate to the resident. In addition, it is recommended that a pain screen be completed during the monthly wellness check followed by an assessment if pain is indicated. In residential health care and adult day health services, a Pain Assessment shall be completed upon admission, when pain is reported or suspected, and every six months and annually thereafter. If it is not possible to achieve the optimal Pain Management plan for the patient/resident, the patient/resident shall be referred for Pain Management to an expert pain consultant. Guided Internet-Based Psycho-Education Intervention Using Cognitive Behavioral Therapy: 1. Assess the resident, especially those with cognitive impairment, for unmet needs which could be interpreted as pain such as hunger, lonliness, depression, need to be toileted, to speak to a loved one, sleeplessness, anxiety and meet the need. The premise is to Page 6 of 30 provide, online education, guidance and interventions which are non-pharmacologic in nature for persons trying to manage chronic pain with little or no access to formal psychological services. The following information was extracted from the entire project as an informational resource for nurses and the patients/residents for whom they provide care: “The most effective treatments for chronic pain involve an interdisciplinary approach (Jeffery, Butler, Stark, & Kane, 2011; Scascighini, Toma, Dober-Spielmann, & Sprott, 2008; Turk, Wilson, & Cahana, 2011). Pharmacologic treatment is most commonly utilized, but other treatments are less consistently accessed. In particular, psychological interventions for chronic pain management are not readily available at a primary care level due to funding, time constraints, and lack of adequately trained staff (Jeffery et al. Internet delivery of evidence-based therapies may benefit individuals with chronic pain. Considering factors such as demographics, environment, supports and symptoms, and building on previous research, an intervention was constructed for delivery via the Internet. By 2016, acetaminophen/hydrocodone, which had been the leading medication prescribed for pain, had dropped from first most prescribed pain medication to the fourth most prescribed drug in the nation, with the volume of prescriptions down 7. Since then, the Ladder has guided clinicians all over the world in treating cancer as well as non-cancer pain. Opioid analgesics include but not limited to: (oxycodone; morphine, transdermal fentanyl; hydromorphone; methadone; combination opioid preparations, such as codeine, hydrocodone, Oxycodone. Considered but not recommended: Propoxyphene, Meperidine, Pentazocine, Butorphanol Before starting opioid therapy for chronic pain, it is recommended, based on person-centered care, a clinician work to establish pain management goals that utilize non-pharmacological methods that will increase the patient/resident’s daily functional abilities at a comfortable level. The level of pain that is tolerated by the established to enable a degree of independence in activities of daily living. With continuing assessment, evaluation and as the increase independence there is a continued reduction in the necessity for narcotic analgesics. Once that is established, person centered goals can be set including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient/resident safety. Pain management for older patients/residents can be challenging given increased risks of both non-opioid pharmacologic therapies (see Recommendation 1) and opioid therapy in this population. Manan Patel (April 25,2017) there are: Page 9 of 30 Age related changes effecting Pain Management: Decrease in pain receptors at the skin Impaired Conduction velocities Loss of neurons at dorsal horns. This may or may not be related to pain and should be investigated before seeking a pharmaceutical solution. Staff and families must rely on patient/resident facial expressions (as illustrated in the Advanced Dementia Pain Scale in the appendix)and body language as pain indicators for the non-verbal person. Reduced renal function and medication clearance even in the absence of renal disease, in patients/residents aged 65 years might have increased susceptibility to accumulation of opioids and a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose (contextual evidence review). Some older adults suffer from cognitive impairment, which can increase risk for medication errors and make opioid-related confusion more dangerous. In addition, older adults are more likely than younger adults to experience co-morbid medical conditions and more likely to receive multiple medications, some of which might interact with opioids (such as benzodiazepines). Clinicians should use additional caution and increased monitoring to minimize risks of opioids prescribed for patients/residents aged 65 years. Experts suggested that clinicians educate older adults receiving opioids to avoid risky medication-related behaviors such as obtaining controlled medications from multiple prescribers and saving unused medications. Clinicians should educate representatives/care givers for those with memory impairment and cognitive decline on safe administration, side effects and risk Page 10 of 30 associated with controlled medications. Clinicians should also implement interventions to mitigate common risks of opioid therapy among older adults, such as exercise or bowel regimens to prevent constipation, risk assessment for falls, and patient/resident monitoring for cognitive impairment 3. Other classes of drugs (corticosteroids, anticonvulsants, clonazepam, carbamazepine, anti-arrhythmics, topical local anesthetics, topical counter-irritants) 4. General Pain Management Principles: A sk about pain regularly B elieve the patient’s/resident’s & family’s reports of pain and what relieves it C hoose appropriate pain control options D eliver interventions in a timely, logical and coordinated fashion E mpower patients/residents and their families D. Acupuncture, reflexology, aroma therapy, music therapy, dance therapy, yoga, hypnosis, relaxation and imagery, distraction and reframing, psychotherapy, peer support group, spiritual, chiropractic, magnet therapy, bio-feedback, meditation, relaxation techniques, Cognitive Behavior Therapy, Self-Management, education. This shall include, but not be limited to, the date, pain rating, pain rating tool, treatment plan, and patient/resident response. The summary should review the medications administered, the numbers of opioids ordered and administered (Information readily available from your pharmacy provider) and the effectiveness of the overall month’s administration. Also, at this assessment of pain management meeting what non-pharmacological interventions have been of benefit or what may be reviewed further with the patient/resident, representative if applicable, the care giver staff and the healthcare provider. The data collected from these monthly meetings may be utilized as part of the Nursing Department’s quality assurance program. The plan shall include mandatory educational programs that address at least the following: 1. Orientation of new staff to the facility’s policies and procedures on pain assessment and management; 2. Training of staff in pain assessment tools; behaviors potentially indicating pain; personal, cultural, spiritual, and/or ethnic beliefs that may impact a patient’s/resident’s perception of pain; age related changes in perception to pain, new equipment and new technologies to assess and monitor a patient’s/resident’s pain status; 3. Incorporation of pain assessment, monitoring and management, non-pharmaceutical and pharmaceutical, into the initial orientation and ongoing education of all appropriate staff; and 4. The facility shall develop a plan by which to collect and analyze data in order to evaluate outcomes or performance. Data analysis shall focus on recommendations for implementing corrective actions and improving performance. Each facility shall develop a policy to define the system for assessing and monitoring patient/resident pain. A written procedure for systematically conducting periodic assessment of a patient’s/resident’s pain, as specified in (b) *above. At a minimum the procedure must specify pain assessment upon admission, upon discharge, and when warranted by changes in a patient’s/resident’s condition and self reporting of pain; 2. Written criteria for the assessment of pain, including, but not limited to: pain intensity or severity, pain character, pain frequency or pattern, or both; pain location, pain duration, precipitating factors, responses to treatment and the personal, cultural, spiritual, and/or ethnic beliefs that may impact an individual’s perception of pain; 3. A written procedure to insure the consistency of pain rating scales across departments within the health care facility; 5. Requirements for documentation of a patient’s/resident’s pain status in the medical record; 6. A procedure for educating patients/residents and, if applicable, their families about pain management when identified as part of their treatment; and 7. A written procedure for systematically coordinating and updating the pain treatment plan of a patient/resident in response to documented pain status. The program is the manner in which professional care team members can provide a consistent approach to assessment and provide feedback on the effectiveness of the program in relation to the patient/resident outcomes and quality of life. The Functional Assessment Screening Questionnaire: Application for Evaluating Pain-Related Disability. Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa, 306 2011 by the American Society for Pain Management Nursing doi:10. Development of a Guided Internet-Based Psycho-Education Intervention Using Cognitive Behavioral Therapy and Self-Management for Individuals With Chronic Pain. Health Care Protocol Acute Pain Assessment and Opioid Prescribing Protcol, Published January 2014.

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The chemical composition of carbidopa/levodopa prevents the drug from dissolving completely in water or other liquid womens health evangeline lilly menosan 60 caps overnight delivery, but a liquid can be prepared for use in certain unusual situations (see Appendix C) womens health 76 tips cheap menosan 60caps online. Carbidopa/levodopa enteral solution breast cancer team names cheap 60 caps menosan with visa, or Duopa menopause period changes discount 60 caps menosan with amex, marketed as Duodopa outside the United States, combines carbidopa/levodopa in a gel that is slowly and consistently pumped through a tube inserted surgically through the stomach into the intestine. This provides a smooth absorption of the medicine and can cut down on motor fluctuations and dyskinesia. One of the major drawbacks to the pump approach is the need for a percutaneous gastrojejunostomy (a small feeding tube). These types of tubes can be the starting locations for infections and other complications. Below you will find information every patient interested in the pump should be familiar with. For more information on Duopa, including information on support services, visit The cassettes are a little smaller than a cellular phone, and usually last about 14-16 hours. Understanding which patients are appropriate for each technique will be important. This is currently not clearly delineated and will require a detailed discussion with the neurologist or expert clinician. Expert practitioners in the Parkinson’s Foundation’s Parkinson’s Outcomes Project report utilizing levodopa more than any other drug for Parkinson’s therapy, and they used levodopa more (not less) as disease durations increased. The term dyskinesia describes involuntary, erratic, writhing movements of the face, arms, legs and/or trunk. These usually occur one to two hours after a dose of levodopa has been absorbed into the bloodstream and is having its peak clinical effect. They can be severe enough to interfere with a person’s normal functioning and to cause discomfort if they can’t be controlled. This makes it difficult to achieve the satisfactory benefit characteristic of the smooth “on” response that is typical of the levodopa response early in the course of the illness. Patients should be reassured that the likelihood of developing dyskinesia remains low early in the disease, and – if it occurs – is usually quite mild. As movement disorder specialists, general neurologists and primary care doctors have learned, patients often require doses of Sinemet that exceed 800 mg/day and can easily tolerate the higher doses used to minimize symptoms. Different dopamine agonists have been created that bind to different dopamine receptors with varying strengths. Dopamine agonists have longer half-lives (longer duration of action) than levodopa and for that reason can be helpful in reducing the intensity of the “wearing-off” reaction or to generally enhance the effect of levodopa. However, certain side effects, such as excessive daytime sleepiness, visual hallucinations, confusion and swelling of the legs, occur more commonly with the use of dopamine agonists than with levodopa. This may be partly due to a higher likelihood of other illnesses (also known as comorbidities) and the greater risk of undesirable interactions between Parkinson’s drugs and drugs taken for other purposes. One possible adverse effect of dopamine agonists is the occurrence of drug-induced compulsive behaviors, such as uncontrolled eating, shopping, gambling and sexual urges. The underlying physiology is likely related to over -)(11#$ 0 stimulation of dopamine receptors in the part of the brain responsible for instant gratification. Dopamine Agonist Started Stopped 2% 2% the Parkinson’s Outcomes Project is the largest clinical study of Parkinson’s in the world. This chart shows the percentage of people using and not using dopamine Used agonists at each of the more than 19,000 visits tracked 38% in the study as of May 2015. Frequency surveys have shown that these abnormal behaviors are more common with dopamine agonists but can also be seen with carbidopa/levodopa. Those at greatest risk include patients with a family history of gambling and those who are younger, unmarried, and/or cigarette smokers. Additional study will likely provide more insight into the true risk associated with the addition of these dopaminergic medications, as the newer questionnaire may be more likely to pick up such behaviors. Remember also that the people suffering from impulse control issues may not have insight into the behavioral problems, and this lack of insight underscores the importance of involving caregivers in any proactive monitoring plan. Neither of these dopamine agonists is ergot derived, nor have they been associated with abnormalities of the heart valves. The side effects are similar, with the addition of usually mild local skin irritation under the patch in up to 40% of patients. Fewer than 5% of those studied in the clinical trials discontinued its use due to skin irritation. The initial formulation of the patch was removed from the market worldwide in 2008 because of technical problems with the delivery system. The original patches had a tendency to show a crystallized substance on their surface after they were stored in pharmacies and in patient medicine cabinets for weeks. Neupro was redesigned and returned in 2012 with dosing available in 1, 2, 3, 4, 6 and 8 mg daily. Its short half-life (average 40 minutes) and chemical structure make it difficult, if not impossible, to take by mouth. In the person affected by severe “off” reactions, during which disabling bradykinesia and rigidity interfere with function, a self-injected dose of Apokyn can reverse the “off” period within minutes and bridge the gap of one to two hours until the next dose of levodopa takes effect. An anti-nausea medication (usually trimethobenzamide or Tigan) is required prior to injection in the early phase of treatment but can be discontinued after the first week or two. Selegiline was shown to delay the need for levodopa by nine months, suggesting neuroprotection, but this benefit may simply have been from the antiparkinson symptom effect of selegiline. Selegiline is available in two formulations: standard oral (Eldepryl, l-deprenyl) and orally disintegrating (Zelapar). Standard oral selegiline is converted to an amphetamine like by-product which may contribute to side effects of jitteriness and confusion. Conversely, Zelapar is dissolved in the mouth and absorbed directly into the bloodstream (no byproduct) without these side effects. Because of Zelapar’s absorption in the mouth, it may be preferred for convenience or out of necessity for the person who has difficulty swallowing. Clinical trials of Azilect as monotherapy or adjunctive therapy showed mild but definite efficacy, and there was also an unproven hint of slowing disease progression. A worldwide, multi-institutional clinical trial of rasagiline’s potential for neuroprotection was published in 2008 and follow-up data from the original studies has also been examined closely. Additional side effects include confusion, hallucinations, discoloration of urine (reddish-brown or rust-colored) and diarrhea. Entacapone is prescribed with each dose of levodopa, whereas tolcapone is taken three times a day, no matter how many doses of levodopa are prescribed. Tolcapone was removed from the American market in the early 2000s because of a few instances of liver toxicity in people who used it. Tolcapone is currently available with the condition that blood tests of liver function be conducted every two to four weeks for the first six months after beginning treatment, then periodically thereafter. It works by providing relief for the motor symptoms as well as reducing “off” time. By combining the two drugs into one tablet, the manufacturer has made pill-taking a little more convenient compared with carbidopa/ levodopa + entacapone taken separately. In addition, there are more dosing options (see table) to better tailor the medication needs to an individual patient. Its mechanisms of action are not fully known, but it is likely that it interacts with multiple receptors at various sites in the brain to achieve its positive effect. Amantadine is cleared from the body by the kidneys, so a person with kidney problems may require a lower dose. Amantadine is most commonly available as a 100 mg capsule, although liquid and tablet forms can also be obtained. The most frequent side effects of Amantadine are nausea, dry mouth, lightheadedness, insomnia, confusion and hallucinations. Stopping the drug will resolve this adverse effect, although if the drug is providing good benefit there is no harm in continuing it. It is believed that acetylcholine and dopamine maintain a delicate equilibrium in the normal brain, which is upset by the depletion of dopamine and the degeneration of dopamine-producing cells. Additionally, research from the Parkinson’s Foundation’s Parkinson’s Outcomes Project has supported the finding that cognitive slowing is a side effect of anticholinergics. The common antihistamine and sleeping agent diphenhydramine (Benadryl) also has anti tremor properties. Ethopropazine, an anticholinergic and an antihistamine, may have fewer side effects but is not available in most U. Although he didn’t differentiate motor from non-motor symptoms, he observed that his patients experienced symptoms of fatigue, confusion, sleep disturbances, constipation, drooling and disturbances of speech and swallowing.

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To raise awareness of the Guidelines and to womens health recipes best order for menosan encourage their use and implementation across Hull and East Riding menopause mood changes buy menosan online, the Task Group will engage the help of Prescribing Advisors and Pain Link Nurses to menstrual seizures purchase menosan on line aid in dissemination pregnancy 7 weeks 3 days cheap menosan 60caps with amex. We will seek sponsorship for a launch event and/or study days, where educational sessions will help reinforce and expand the knowledge to be derived from each of the main Guideline sections. Future evaluation will be via prescribing audits, monitoring use of Fentanyl patches and surveys as appropriate. The Section on Patient Centred Care C1-C3 is broadly based on the Reference: Patient-Centred Medicine Transforming the Clinical Method by Stewart et al 1995. One spends the day joking with work colleagues about how unfit and ‘old’ they feel. The other, who had a lump removed for breast cancer 2 years earlier, is frightened that this pain represents spread of the cancer, can’t face going to work, becomes tearful, and starts planning her funeral. From the doctor’s perspective the ‘disease’ process is the same, but the patient’s experience of their ‘illness’ is quite different and has potentially profound influences on their health, self-esteem, mental state, ability to cope and finances. Disease Framework Illness Experience Symptoms Ideas Signs Concerns Investigations Expectations Underlying pathology Feelings Thoughts Effects on Life Unique Personal Story – Narrative For someone with acute appendicitis the disease perspective perhaps more accurately reflects the patient’s prime concern. However in more complex situations, such as chronic pain and cancer pain, unless we understand the illness experience, in particular the significance or meaning of the pain to the person, we are unlikely to deal effectively with the situation. This section aims to help healthcare professionals explore all aspects of pain and to understand why they may be important. During a consultation the most important thing is to listen actively to the patient, showing empathy and a desire to fully understand the situation. Use of open questions and encouragement allows the patient to cover those aspects that they feel are important. Extra encouragement may be needed in areas that are not always considered in more straightforward consultations. A consultation that feels like a relaxed conversation will often result in more information than a list of questions. The suggested questions in the green boxes are not intended to be used as a list but are options when trying to steer the consultation in a particular direction or explore a particular aspect in more depth. The consultation should be seen very much as a partnership which aims to understand the issues and find mutual agreement about the best way to move forward. Possible questions that may help explore the significance of the pain to the patient include: Questions might include: What are your thoughts about this pain An attempt to understand the whole person can often improve our understanding and allow us to give more helpful suggestions for managing the pain. This includes their personality and usual coping mechanisms, the influence of past events on current behaviours in response to illness and care, the role of spirituality in their life, how family dynamics and social support affect their responses to pain. Other aspects affect pain less directly: Participation in leisure activities improves mood and widens a person’s social support network. A person’s education can influence how effective they are at accessing health services, information and help. Occupation can help give an insight into social status, skills, perspective on life – and much more. Financial concerns can have a profound influence on well-being and the ability to cope with pain or suggested treatment options. Different groups can vary in their perceptions of illness causation, perspectives on treatment, attitudes and expectations of healthcare and resources, specific behaviours and responses to pain and illness sanctioned by the prevailing culture. Specific needs such as language make it even more difficult to articulate needs and to receive support. At the same time we need to be wary of applying stereotypes, perhaps checking out any assumptions that we might make with the individual. This may be expressed in terms of an outside influence, which is sometimes referred to as God. Spiritual well-being may be expressed in terms of a sense of reassurance, comfort, hope or peace. Spirituality is part of the holistic assessment of any patient and their situation, but may be most helpful in patients with chronic or life threatening conditions. It is important to avoid sounding judgemental throughout the consultation, but perhaps particularly when exploring spirituality. Illness often involves physical, emotional, intellectual and spiritual components, none more so than pain. Pain may prompt people to question the meaning of life or reflect on their lifestyle and values. They may seek to explain the situation by blaming something or someone outside themselves or harbour thoughts of guilt. The illness or the possibility of surgery may imply to many people the threat of shortening of life. This may lead to a change in priorities, sometimes a desire to ‘put things right’. Just having time lying in bed or restricted in activities by illness can lead people to reappraise their focus and values in life. Pain and illness can affect an individual spiritually, perhaps strengthening reliance on their belief system to see them through or it can leave people angry and lost, as their belief system seems to have let them down. Illness may affect family and friends in different ways, some being supportive, caring and helpful, and others withdrawing at a time of need. Loss of health can lead to a bereavement type reaction, particularly when there does not seem to be a cure in sight. Disbelief, searching, anger, tearfulness, anxiety and depression, are all common as people struggle to come to terms with the situation. Spiritual questions often feature highly in this struggle and healthcare professionals may well be in a position to help their patients explore these concerns and when needed, refer on. Usually this is considered when pain is not controllable with drugs or physical therapies. The home situation may be complex and there may be deeper issues with ‘unfinished business’ something which has not been resolved that is expressed in terms of physical pain. There may be unresolved anger, a sense of hopelessness, inability to trust, lack of inner peace, or a sense of disconnectedness or fragmentation. Spiritual pain is often expressed and felt by others in terms of suffering, anguish or torment rather than a focus on the physical aspects. The threat of death perceived at the time of an accident, surgery, diagnosis or the real prospect of impending death may raise questions about dying and practicalities after death, but also questions about an afterlife, what does live on and what can be left behind for loved ones to cherish. Spirituality includes but is not by any means restricted to religious beliefs and practices. Many people without a formal religion are comforted by prayers either said with them or just by knowing that others are praying for them. Unconventional beliefs may be particularly difficult to express but can be a source of distress. Chaplains are often willing to discuss such issues with patients who do not have a formal religious belief. Staff looking after patients with particularly distressing symptoms are often more aware of their own spirituality and may go through many of the same emotions. A situation may be particularly distressing because it is horrific or symptoms are uncontrollable or because the staff member identifies with the situation. If the patient has characteristics in common with the staff member or their relative, if there are interests in common, if they feel ‘this could be me’, the situation can cause a wide range of emotions. Options for referral or support: Macmillan nurses are often well placed to explore spiritual issues with patients and usually accept referrals to consider this aspect of patient care. The oncology health centres similarly would consider spirituality as part of their role. The Chaplaincy team in the hospital and the Social Work and Chaplaincy team at Dove House Hospice accept referrals for their own patients. When it is clear that there is time to explore their deepest fears and hopes then, sometimes, the source of their greatest concern or comfort is uncovered. Sometimes reassurance that it is normal to have these fears is very comforting, but it is important not to ‘normalise’ the experience without first understanding the situation.

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