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By A. Irhabar. Youngstown State University. 2019.

Similarly viagra with dapoxetine 100/60mg low price, the use of standardized retinal video Use of the standard protocol for color-coding retinal recording evaluated using a defned protocol drawings is recommended purchase viagra with dapoxetine 100/60 mg mastercard. Defcits diffuse) generic viagra with dapoxetine 100/60mg with mastercard, capillary loss and dilation and various in contrast sensitivity may occur before the 29 168 onset of clinically detectable retinopathy discount viagra with dapoxetine 100/60 mg free shipping. More that a more aggressive blood pressure goal frequent examination may be needed depending (e. Therefore, color vision Unfortunately, individuals may not experience testing may be appropriate. However, the use symptoms until relatively late, at which time treatment of color vision testing for the diagnosis of may be less effective. Persons with Non-retinal Ocular Complications of Follow-up every 2 to 3 months in consultation with Diabetes Mellitus an ophthalmologist experienced in the management of diabetic retinal disease is recommended. See Table 5 for a brief outline of the management of non-retinal ocular complications. A summary of follow-up visits for management of patients with retinal complications of diabetes can 3. Fasting blood glucose values of 126 used to identify clusters of risk factors for diabetes mg/dl or greater indicate the need for further and coronary heart disease in patients in large health evaluation or treatment. Basis for Treatment of diabetes should be consistent with current reatment recommendations depend upon the recommendations of care for each condition. Treatment therapy regimens is beyond the scope of this decisions should refect the patient’s preferences and Guideline, Table 5 briefy reviews current clinical values. Appendix Figure 1 presents a fowchart for practice for management of common non-retinal the management of the patient with undiagnosed ocular and visual complications. Persons with Undiagnosed Diabetes Mellitus care, and include education on the subject and recommendations for follow-up visits. Refractive error changes Assess refractive error, distance and near and pinhole acuity as recommended in the Optometric Clinical Practice Guidelines on Care of the Patient with Myopia and Care of the Patient with Hyperopia. Change in spectacle or contact lenses prescription, as indicated by the patient’s visual requirements, with special attention to the person’s level of glycemic control. Counsel patients about variable refractive status due to fuctuations in blood glucose. Functional Changes in color vision Perform color vision assessment that is sensitive to acquired (i. Changes in visual felds Assess visual feld changes and manage as recommended in the Optometric Clinical Practice Guideline on Care of the Patient with Visual Impairment. Eye Cranial nerve palsies Assess multiple diagnostic positions of gaze; tests of smooth movement pursuits (versions and ductions), and saccades. Pupils Sluggish pupillary refexes Rule out optic neuropathy and other neurological etiologies. Cornea Reduced corneal sensitivity Monitor for abrasions, keratitis, or ulcerations. Monitor contact lens wear as recommended in the Optometric Clinical Practice Guideline on Care of the Patient with Contact Lenses. Recurrent corneal erosions Prescribe sodium chloride solution/ointment or ocular surface lubricant. Iris Rubeosis iridis Gonioscopy to rule out anterior chamber angle involvement (neovascularization on the iris) and neovascular glaucoma. If functional defcits remain, manage as recommended in the Optometric Clinical Practice Guideline on Care of the Patient with Visual Impairment. Surgery may be indicated, if adequate visualization of the retina is no longer possible or if visual acuity is decreased secondary to the cataract. Refer to Optometric Clinical Practice Guideline on Care of the Adult Patient with Cataract for more information. Detachment Consultation with an ophthalmologist experienced in the management of diabetic retinal disease. Optic Disc Papillopathy Management of diabetic papillopathy or ischemic optic neuropathy may require consultation with a neuro- Ischemic optic neuropathy ophthalmologist or neurologist to rule out all other potential etiologies. Since the relative diseases due to the high rate of patients that may risk of vision loss in patients without high-risk subsequently need laser or surgical intervention. The follow- proliferation of fbrous tissue on the optic disc or up interval may be extended based on disease elsewhere on the retina. Frequent consultation with an ophthalmologist experienced follow-up is needed to determine whether in the management of diabetic retinal disease. Such patients should be re- loss, increased the chance of visual improvement, examined within 4 to 6 months. Follow-up for decreased the frequency of persistent macular proper management of the retinopathy can be 28,29,31,33 edema, and caused only minor visual feld losses. An average [Evidence Strength: A, Recommendation: A) of 8 to 9 intravitreal injections may be needed in the frst year of treatment. Furthermore, focal/grid laser at the known to be associated with an increased initiation of intravitreal ranibizumab is no better, risk of stroke. It is unknown if a substantially and is possibly worse than, deferring laser for at smaller dose, when used intravitreally, has 177 least 24 weeks in these eyes. The trials employing the same standardized procedure risk of such events with systemic administration for the preparation and intravitreal injection using was found to be 5 percent. Telehealth Programs The vast majority of persons with diabetes will develop diabetic retinopathy at some point during Ocular telehealth programs can be an integral the course of the disease. Studies across multiple aware that retinopathy may exist even when vision is populations demonstrate that the prevalence of good and in the absence of any symptoms. Optometrists should help patients understand that timely follow-up examinations and management are The implementation of national coverage of universal critical for early diagnosis and intervention, when retinal evaluation for all patients with diabetes indicated, to reduce the risk of vision loss from mellitus has been shown to reduce the incidence diabetic retinopathy. Individuals should also be of blindness among patients with diabetes by as informed about their higher risk for other non-retinal 192,193 much as 95 percent. Telehealth programs have ocular complications, such as cataracts, neovascular been largely used in these initiatives and rely on glaucoma and open angle glaucoma, and informed the digital capture and transmission of standardized about available optometric vision rehabilitation care ocular images and patient health information for to address loss of visual function. Proper monitoring interpretation and evaluation by trained observers and timely treatment can result in subsequent saving who can generate a treatment and care plan. Telehealth has the potential to Individuals should also be encouraged to participate deliver economical, high quality eye care locally, in diabetes education programs. Substantial opportunity exists to detection and assessment of the severity of diabetic further improve diabetes control and, thus, to reduce 188 195 retinal disease when implemented appropriately. In addition, there is a clear need to increase the Specifc emphasis should be placed on the beneft frequency of smoking cessation counseling for of reduction in elevated A1C in lowering the risk of patients with diabetes, given the strong association damage. For the individual with proliferative retinopathy, the risks of smoking related to diabetes and the same one percent increase in A1C results in 145 encouraged to quit smoking and/or seek smoking 60,92,203 percent progression over 10 years. Prognosis and Follow-Up Persons should be informed of the relationship between the level of glycemic control and the risk of Disability and premature death are not inevitable 43 9 consequences of diabetes. Lifestyle and behavioral Appropriate communication with the patient’s primary modifcation, and pharmacotherapy, can delay care physician (as with any referral consultant) is progression to type 2 diabetes among persons critical for proper coordination of the patient’s care. All health care personnel involved with the individual’s care should be aware All persons with diabetes mellitus are at risk for of his or her overall medical status. These Adherence to treatment recommendations to letters also provide permanent documentation for the maintain optimal control of blood glucose levels is patient’s record. These fndings mellitus includes individualized glucose targets may be due to improvements in the management and lifestyle modifcations. The individual’s age, of risk factors (hyperglycemia, hypertension and weight, comorbidities, race/ethnicity, and physiologic hyperlipidema) and overall diabetes care, along with differences need to be considered in determining 115 78,208 earlier identifcation of diabetes. Others, who have only limited presence and severity of retinopathy at the time of residual insulin secretion, often require insulin for 207 the patient’s initial eye examination. Individuals with type 1 diabetes, who have extensive beta-cell destruction The follow-up examination of persons with diabetic and therefore no residual insulin secretion, require retinopathy should be scheduled in accordance with 6 insulin for survival. While previous standards for diabetes management emphasized the need to maintain glucose levels Laser photocoagulation greatly improves the as near to normal as safely possible, current prognosis for maintaining useful vision. According to (panretinal) laser photocoagulation reduces the risk of the American Diabetes Association, reducing A1C severe vision loss (best visual acuity < 5/200) to less levels to less than 7 percent has been shown to than 2 percent per patient. For individuals with the relative risk of severe hypoglycemia by 30 214 a history of severe hypoglycemia, limited life percent. The classic symptoms of with diabetes should be individualized, taking hypoglycemia are hunger, shakiness, nervousness, 215 into consideration their risk of hypoglycemia, sweating, or weakness. While hypoglycemia is anticipated life expectancy, duration of disease more common in type 1 diabetes, the incidence is and co-morbid conditions. However, as persons experience more frequent low blood In persons with type 2 diabetes mellitus, intensive glucose, they gradually lose the classic symptoms glucose control may reduce microvascular disease, of hypoglycemia due to defective glucose counter 210 216 retinopathy, nephropathy, cataract and neuropathy, regulation (hypoglycemia unawareness). To help (B/B) non-fatal myocardial infarction and lower identify persons experiencing hypoglycemia, the extremity amputation. It may be prudent for optometrists’ offces to maintain a blood glucose meter and single use lancet Intensive glucose control in individuals with type 2 devices for confrming hypoglycemia and its resolution diabetes and established cardiovascular disease or where state laws permit. Check blood glucose to confrm hypoglycemia have no signifcant impact on the risk for nonfatal (blood glucose <70 mg/dL). If patient is conscious, give 15 g of simple as a strategy for reducing such events in individuals carbohydrates orally as immediate treatment. If initial blood glucose is While achieving tight glycemic control may reduce less than 50 mg/dL, give 30 g of simple 45 carbohydrates. If blood glucose is less than 70 mg/dL repeat However, the Wisconsin Epidemiologic Study of the treatment (step 2) until blood glucose returns Diabetic Retinopathy showed that elevated blood to at least 90 mg/dL. Inject glucagon intramuscularly, if it is available in the Individuals with type 2 diabetes mellitus have an offce. Slight Recommendation: B] variations in optimum blood pressure for people As a preventive approach, persons with with diabetes can be cited in the literature. Blood diabetes should be treated as if they have pressure of <140/80 mmHg has been recommended 78 cardiovascular disease. There is emerging evidence that normalizing blood lipid levels may also reduce the risk of retinopathy.

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The events causing most deaths in severe malaria are related to cerebral involvement (cerebral malaria) viagra with dapoxetine 100/60 mg otc, severe anaemia discount viagra with dapoxetine 100/60 mg fast delivery, hypoglycaemia cheap 100/60mg viagra with dapoxetine visa, severe dehydration purchase viagra with dapoxetine 100/60mg mastercard, renal failure and respiratory acidosis. The diagnosis of severe malaria is based on clinical features and confirmed with laboratory testing. While confirmation of the diagnosis is necessary treatment must be started promptly and not withheld while confirming the diagnosis. To prepare this, draw 2 mls of Quinine 600 mg and add 4 mls of sterile water or saline (not dextrose). Repeat infusion 8 hourly until patient can swallow, then change to Quinine, oral, 10mg/kg (maximum dose 600 mg), 8 hourly to complete 7 days treatment. Note Artemether should not be given in the first trimester of pregnancy unless there are no suitable alternatives. In most other respects, however, the treatment of severe malaria in pregnancy shall be the same as the treatment of severe malaria for the general population. Appropriate drug treatment, as shown in the tables (19-8, 19-9, and 19-10), must be initiated prior to transferring the patient. Note The drug of choice for uncomplicated malaria for pregnant women in the first trimester is oral Quinine. However their use should not be withheld in cases where they are considered to be life saving, or where other antimalarials are considered to be unsuitable. Fourth Dose: May be given, provided it is at least one month after the last dose and at least one month before anticipated delivery. Poor hygiene or contact of bare skin with soil in which the worm or its eggs live predisposes individuals to infestation. It is important to prevent this condition by examining the eyes of all sick and malnourished children. The foreign body may be either in the conjunctival sac, on the cornea or inside the eyeball (intraocular). A history of the likely nature of the foreign body aids in its detection and removal. The foreign body may be seen by careful inspection of the cornea or conjunctival sac. Good light is needed and a magnifying glass may be required to detect corneal foreign bodies. Acute red eye may have a history of injury to the eye or there may be no history of injury. There may be a foreign body on the cornea or on the conjunctiva, under the eyelid. A blunt injury may cause a subconjunctival haemorrhage or bleeding into the anterior chamber (hyphaema). Corneal ulcer • 1% Tetracycline eye ointment and refer to the specialist immediately. Also refer acute conjunctivitis which shows no improvement after 48 hours of treatment. The different types of conjunctivitis are: • Bacterial Conjunctivitis • Viral Conjunctivitis • Trachoma • Allergic Conjunctivitis e. Glaucoma may produce severe loss of vision and blindness without prior warning symptoms and must therefore be screened for in all adults beyond the age of 40 years, especially those with a positive family history. This occurs when there is an obstruction of the upper airway from the nasopharnyx down to the trachea and main bronchi. The disease tends to run an extremely rapid course (4-6 hours) to respiratory failure and death. It is more common in children, however, the incidence has reduced due to the current immunisation schedule with the pentavalent vaccine. However, it is important to diagnose streptococcal pharyngitis since it may give rise to abscesses in the throat (retropharyngeal and peritonsillar abscess) as well as complications that involve organs like the kidneys and the heart. Streptococcal throat infections require treatment with antibiotics in order to reduce the complications noted above. This infection does not occur in children less than 6 years because their air spaces are not well developed. Therefore it may, especially in children, follow a common cold or a sore-throat or measles infection. Untreated or poorly managed cases may lead to complications such as mastoiditis, chronic otitis media, deafness, meningitis and brain abscess. Viral infections resulting in common cold (Rhinitis), sinusitis, pharyngitis and tonsillitis, influenza infections and nasopharyngitis are precursors to bacterial infections. If pain is still severe or pus discharge still present, repeat otoscopy, send swab of discharge for bacteriological examination and change to alternative antibiotic therapy. Acute re-infection associated with fever and pain is usually related to an obstruction to drainage through the perforated drum with secondary infection by streptococci, pneumococci or gram negative organisms, A chronically draining ear can only heal if it is dry. Drying the ear is time- consuming for both the health worker and the mother but it is the only effective measure. Pharmacological treatment (Evidence rating: C) If the ulcers look infected • Amoxycillin, oral, Adults 500 mg 8 hourly for 5 days; Children 6-12 years; 250 mg 8 hourly for 5 days 1-5 years; 125 mg 8 hourly for 5 days < 1 year; 62. There are many causes of low back pain several of which can be determined with reasonable accuracy from a good clinical history and physical examination. In some patients however, no cause will be found and these people are described as having non-specific back pain. Whereas most back pain may not represent serious problems, clinical features that may suggest that the back pain may be serious include, recent onset, weight loss, anaemia, localized pain in the dorsal spine, fever and symptoms elsewhere e. In such cases management is by reassurance and treatment of depression if appropriate. Slipping forward of a vertebra upon the one below • Narrowed spinal canal from spinal stenosis • Psychogenic pain: The back is a common site of psychogenic pain. Weight bearing joints (hips, knees), cervical and lumbar spine and the metacarpo-phalangeal and distal- interphalangeal joints of the hands are commonly affected. Instead, they should have alternatives such as paracetamol 1g 8 hourly or tramadol 50 mg 8 hourly. Also refer other complications such as lumbar spinal stenosis, cervical spondylosis and nerve compression for specialist management. Other organs such as the lungs, kidneys, eyes and the haematopoietic system may occasionally be affected. Rheumatoid factor is positive in older girls in whom the disease course is similar to the adult type. Occasionally single joint (proximal interphalangeal joint) and swollen knee may be the only joints affected. This is a complex disease with variable presentations, progression of disease and prognosis. Due to the systemic nature of the disease there is a need for the involvement of multiple medical specialists in the care of these patients. The majority are due to non-gonococcal bacteria whereas the remaining cases may follow gonorrhoeal infection. Good prognosis depends on early initiation of appropriate antibiotic treatment which should begin immediately diagnosis is suspected while ensuring that samples are taken for appropriate investigations. Antibiotic treatment, including initial parenteral and subsequent oral preparations, must be continued for a total of 6 weeks. Additional features include rash (macular, vesicular or pustular), tenosynovitis and urethral discharge. However, direct infection of the bone may also occur in fractured bones that communicate with the exterior (i. Pharmacological treatment with antibiotics should be by the parenteral route for two weeks followed by the oral route for 4 weeks. It may bleed, may be contaminated with dirt and other foreign matter and may be associated with broken bones. Pharmacological treatment (Evidence rating: C) • Tetanus prophylaxis for all potentially contaminated wounds, followed by booster doses of tetanus toxoid as appropriate (see section on Immunization). Scrub dirty wounds with antiseptic solution and irrigate with dilute hydrogen peroxide and saline. Lift up all flaps of skin, clean under them, excise all dead tissue and cover the wound with sterile gauze. Do not use Eusol, which is both irritant and exposes patient to unnecessary borate levels Dress infected wound as often as needed with normal saline or povidone iodine lotion. Take wound swab for culture and sensitivity test if possible and start Amoxicillin (Amoxycillin) while waiting for results of wound culture • Amoxicillin (Amoxycillin), oral, Adults 500 mg 8 hourly Children 6 -12 years; 250 mg 8 hourly 1-5 years; 125 mg 8 hourly 1 year; 62. These bacteria live predominantly in the soil, so it is easy to get this infection whenever a break in the skin is not cleaned properly. Noise, bright light, touching the body or moving part of the body will trigger muscle spasms in tetanus. Infection is usually via the umbilical cord if it is not kept clean or if non-sterilised instruments or dressings are used. Cut umbilical cord with sterile instrument, clean with methylated spirit (alcohol) and leave uncovered. To prevent tetanus in patients with potentially contaminated wounds (tetanus prone wound), provide adequate wound toileting (see section on Wounds) and also provide tetanus prophylaxis (see section on Immunization). A tetanus-prone wound is one sustained more than 6 hours before surgical treatment or any interval after puncture injury or is contaminated by soil/manure or shows much devitalised tissue or is septic or is associated with compound fractures or contains foreign bodies Diagnosis of tetanus is clinical, and no laboratory investigations are required. All cases of snake bites (venomous/non-venomous) should be observed for at least 6 hours. The role of tourniquets and incision over the site of the bite are controversial issues and are to be avoided. Do not move the limb that has been bitten-the more it is moved, the faster the poison spreads.

Volume of Distribution A measure of how widely a drug is distrib- uted throughout the body buy generic viagra with dapoxetine 100/60 mg. The project team would like to thank the following clinicians buy generic viagra with dapoxetine 100/60mg online, reviewers and leaders for their support viagra with dapoxetine 100/60 mg fast delivery, enthusiasm and expertise effective viagra with dapoxetine 100/60 mg. Guidance is provided for key medicine safety topics relevant to the care of older adults. This guidance is based on current legislation, best available evidence and published guidelines, and is consistent with the New Zealand medicines strategy, Actioning Medicines New Zealand (Associate Minister of Health and Minister of Health 2010). The Medicines Care Guides are designed to support best practice in residential aged care environments and do not replace sound clinical judgement, facility-specifc policies and procedures, or current legislation. It is envisaged that the Medicines Care Guides will be utilised by managers, registered nurses, enrolled nurses, health care assistants, and other contracted health professionals who work in residential aged care facilities. Care environments include rest homes, dementia units, private hospitals, and psychogeriatric hospitals. In utilising these guides, it is important to be aware of the context and scope for which they were developed and consider other documents that guide the provision of services in New Zealand, such as the Health and Disability Service Standards 2008. Medicines Care Guides for Residential Aged Care 1 Medicines Management A comprehensive medicines management system is required in residential aged care facilities to manage the safe and appropriate prescribing, dispensing, supply, administration, review, storage, disposal and reconciliation of medicines. Policies and procedures should be clearly documented and available to all staff at all times. Staff involved in medicines management are required to work within their scope of practice and demonstrate their competence to provide this service. Access to specialist medicines education and advice for residents and staff must be made available The clinical fle should include documentation that records all relevant details to support safe medicines management and should comply with legislation, regulations, standards and guidelines. The safety of residents, visitors, staff and contractors must be maintained through appropriate storage and access to medicines. Multidisciplinary team involvement The multidisciplinary team can include but is not limited to the following: Resident/Representative • The resident or their representative is included in the multidisciplinary team and agrees to and is kept informed of medicine-related aspects of their care. Manager • Contracts services of health professionals (eg, pharmacists; general practitioners, nurse practitioners, registered nurses; dieticians, etc) to support safe, resident focused medicines management • Ensures there are suffcient appropriately qualifed staff to meet the needs of the residents • Ensures there are appropriate quality and risk management activities to support safe medicines management. Prescribing – Medical or nurse practitioner • Maintains current evidence-based knowledge of medicines relevant to the care of older adults • Provides timely, legible, accurate and legal medicine prescriptions that meet the individual needs of the residents • Considers non-pharmaceutical alternatives • Liaises with the pharmacist and facility staff regarding medicine prescriptions as necessary • Liaises with the multidisciplinary team to ensure appropriate ongoing care to residents • Provides advice and direction to staff regarding medicines’ administration, monitoring and management • Documents, diagnoses and treatment rationale in the clinical fle • Participates in medicines reconciliation for residents • Participates in multidisciplinary medicine reviews • Is actively involved in quality and risk management activities related to safe medicines management, including review of policy and procedures • Provides learning opportunities for staff related to resident diagnoses and medicines management. Administration – Registered nurse • Maintains current evidence-based knowledge relevant to the care of older adults • Assesses and identifes possible individual risk factors related to medicines • Monitors changes in health status and responds accordingly • Identifes signs and symptoms indicating adverse medicine reactions • Liaises with the manager and the multidisciplinary team to provide services that meet the needs of the resident • Participates in multidisciplinary medicine reviews • Provides direction and/or supervision for unregulated staff as required • Documents information regarding medicines and their effects on the resident in the clinical fle • Contacts the prescriber regarding changes in health status where necessary • Participates in medicines reconciliation for residents • Participates in multidisciplinary medicine reviews • Is actively involved in quality and risk management activities related to safe medicines management, including review of policy and procedures • Provides learning opportunities for staff. Medicines Care Guides for Residential Aged Care 3 Medicines Administration Competency Before giving medicines, all staff must demonstrate that they have knowledge, understanding and practical abilities to be considered as competent. Skill and knowledge will be assessed by a registered nurse who has demonstrated competency. Safe practice includes: For more on scopes of practice, • Following organisation policy refer: Nursing Council of New Zealand: • Accurate documentation www. For staff administering medicines, education should be provided during Once competent: orientation and reviewed at least Registered nurses and nurse practitioners can: annually. Bureau staff should be orientated to organisational policies and procedures Enrolled nurses can: that are applicable to the shift. Health care assistants/caregivers can: • Check and administer oral, topical and rectal medicines and under the direction and delegation of a registered nurse (eg, oral from a unit dose pack [blister pack], topical medicines, suppositories). Insulin administration specifc competence is required for administering subcutaneous insulin. Right to refuse Right indication 3 Re-check the medicine order and medicine prior to Right documentation administering (not required for unit dose packs). Name and photograph of Medicine, Allergy or Duplicate resident checked against Visually dose, route, Medicine hypersensitivity name resident name on medicine inspect time last dose stickers stickers being administered given Think Registered nurses: Be aware Be cognisant of cultural Pre-administration 5 Rs + 3 of individual resident safety considerations. Right to refuse 3 Re-check the medicine order and medicine (under some circumstances) after preparation but before administering. Give medicine and observe Right reason that it has been Right documentation swallowed safely Perform hand hygiene Continued over page Medicines Care Guides for Residential Aged Care 5 Medicines Administration Safety (Continued) 1. Explain why the medicine is prescribed and offer medicine again Document the episode in the clinical fle and medicines administration record. Resident education and information Document the education and/or information provided to the resident or their representative regarding medicines in the resident’s clinical fle. Resident’s response to medicines Document the effect of medicines on the resident in their clinical fle, including all adverse medicine reactions. Common errors include: Referrals Wrong resident Maintain a copy of referrals to other health Wrong medicine professionals related to a resident’s medicines Similar sounding medicine names management in their clinical fle. Wrong dose/strength/duplication Misinterpretation of units Incident reporting (eg, grams, milligrams, micrograms) • Record all medicine errors on an incident form. Photos Date photos used to identify residents and ensure they resemble their current appearance. Medicines Care Guides for Residential Aged Care 7 Documentation, Incident Reporting and Quality Activities (Continued) Quality and risk activities • Encourage a quality improvement approach. Legal considerations These include: • professional accountability • complete documentation of events. Any suspected adverse reactions should be reported to the Centre for Adverse Reactions Monitoring. Medicines Care Guides for Residential Aged Care 9 Adverse Medicine Reactions – Contributing factors to adverse reactions Inform the prescriber immediately with pharmacist notifcation of potential interactions or adverse reactions. Increased sensitivity to the Cell mediator receptors and target organs have reduced ability effects of medicines with age to compensate. Reduced ability to The liver, lungs and kidneys become less able to metabolise metabolise medicines medicines with age. This may refect a woman’s relatively smaller size for given Female gender medicine doses. Many adverse effects are dose related, and identifying the Dose right dose can be made more diffcult due to weight and body composition in older adults. The incidence of adverse effects tends to increase with the Polypharmacy number of medicines taken. A history of signifcant adverse effects to medicines increases History the risk of further adverse reactions. Hereditary factors can determine the relative defciency of Genetic factors enzyme(s) involved in the metabolism of some medicines, which can increase the risk for adverse reactions. Poor adherence may be unintentional, or intentional due to Not taking medicines as resident confusion, complex medicine regimens, side-effects, prescribed adverse medicine reactions or medicine costs. Antibiotics, anti-infammatories and antihypertensives are the most common causes of adverse medicine reactions in older adults. Rest home For those residents who have recently started a Controlled drugs can only be provided by controlled drug, skilled assessment of treatment individual named prescription and must be kept effcacy is required and should be carried out by in a controlled drugs cabinet or locked cupboard. Yes No A separate page is to be used for each medicine and strength of the medicine It is recommended Resident requires controlled two staff are on drugs and is unstable or duty to witness requires frequent assessment Quantity Time and controlled drug (eg, residents who are: Resident’s Name of administration in deteriorating, require and dose of date of name prescriber the rest home palliative care, in acute medicine administration pain and/or delirious). Storing • The prescriber’s registration number must be included on all prescription forms. Special and resident-specifc orders • Record the date medicines are opened, such as 12. It is recommended that the prescriber’s • Check monthly for expired, damaged and registration number also be included on the unused medicines. Changing medicine orders, including changing unit dose packs and discharged/deceased residents • Send new medicine orders to the pharmacy to ensure a supply is received within an appropriate timeframe. Resources • Provide access to current medicines information resources for the staff, residents and health professionals. Sharing medicines • Never give medicine to anyone other than the person for whom it is labelled. Bulk supply • Bulk supply is only suitable for facilities with hospital certifcation. Medicines Care Guides for Residential Aged Care 15 Cytotoxic Medicines • Cytotoxic medicines have the ability to kill or slow the growth of living cells and are used to treat conditions such as cancer, rheumatoid arthritis and myeloproliferative disorders. The following cytotoxic medicines are sometimes prescribed for residents in residential aged care: • methotrexate Cytotoxic • hydroxyurea medicines • chlorambucil • cyclophosphamide • azathioprine • fuorouacil. Cytotoxic medicines should be stored in a locked cabinet, in a locked Storage medicine room, separate from other medicines. Medicines Care Guides for Residential Aged Care 17 Residents Self-Medicating There are many reasons why it might be preferable for residents to self-medicate (eg, to maintain autonomy or as part of a rehabilitation programme). As part of the assessment, it may be benefcial to ask the resident what they know about their medicines and conditions, which medicines are actually being taken and how they take them, and any benefcial and/or unwanted effects experiences they have had. Alternative medicines • Include over-the-counter, complementary, homeopathic, naturopathic, traditional and supplementary medicines on the medicines chart as these can sometimes cause side effects, adverse drug reactions and interactions. Monitoring and documentation • Identify on the medicines chart that the resident is self-medicating. Storage • Provide locked storage that is only accessible to the resident and authorised staff. Medicines management for facility leave • Document in the clinical fle who is taking responsibility for medicines management while resident is on leave. Medicines Care Guides for Residential Aged Care 19 Residents Self-Medicating – Factors to considerTher Use the following guide to assess a resident’s ability to self-medicate safely. If their ability is on the blue end of each indicator, they are likely to be able to self-medicate. However, if their ability for any indication is on the red section, the ability to self-medicate is questionable. Self-medication risk Low Medium High Medicine Minimal side effects/adverse effects Some adverse effects – Narrow therapeutic index, potentially not serious serious adverse effects Administration diffculty Topical/oral Subcutaneous/intramuscular/rectal/vaginal Intravenous infusion/pump Functional ability Independent/previous self-medication Some functional dependency Dependent Environment Own home/supported living Rest home/private hospital Hospital ward/intensive care unit Monitoring required Responses easily judged Simple questions/physical, cognitive assessment Complex monitoring and assessment Packaging/regimen complexity Unit dose packaging Simple regimen Moderately complex Complex regimen Medicines not (eg, blister-packed) Few changes regimen Frequent changes pre-packaged 20 Medicines Care Guides for Residential Aged Care Medicines Review Multidisciplinary team medicines review Assessment for Medicines reviews Resident and/or family Resident input Education for staff medicines review to be undertaken education/information Include: • On admission • Direct contact • Disease process Evidence-based practice • Goals of care • Every 3 months between reviewers • Medicines desired regarding medicines • Resident medicines • When health and resident/ effects/benefts used within the facility history status changes representative offers • Potential side including: • Allergies/sensitivities essential advantages. When stopping medicines, consider reducing them gradually as stopping medicines abruptly can cause unwanted effects.

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