By G. Fabio. Florida State University. 2018.

The medication history is the part of the patient interview that provides the pharmacist the opportunity to utilize his or her expertise by precisely collecting each component of the medication history (however 100 mg lasix fast delivery blood pressure chart teenager, a medication history may also be collected independent of a comprehensive patient interview) buy 40 mg lasix overnight delivery blood pressure dizziness. The questions that you ask the patient, as well as the technique used, will enable you to learn exactly how, when, and why a patient takes each medication, as well as about any adverse reactions, allergies, or issues with medication cost the patient may have experienced. The approach to the patient interview and medication history will change based on the setting in which you are practicing. For example, if the setting is a community pharmacy and you are responding to a problem that may allow for self-care, your questions will be directed at meticulously characterizing the patient’s complaint and obtaining specific information that will influence your assessment and plan for the patient. However, if you are in a hospital, the focus of the interview may need to be modified based on the patient’s condition and the particular unit or department in which he or she is being cared for so that the patient’s needs may be met. Regardless of the setting, your goal during the interview will be to provide patient-centered care; this can be accomplished by combining your pharmaco- therapeutic knowledge with a solid foundation of excellent communication and patient-interviewing skills. Excelling in these communication skills is a learned technique that takes time and practice to master. Once these skills are employed in practice, the relationship that is developed with the patient is often stronger, allowing for the patient to have increased confidence and trust in your role as a healthcare provider. The purpose of this chapter is to describe the various components of the compre- hensive health history and to provide an overview of the skills and techniques required when communicating with the patient. This chapter will focus on the best practices to follow when collecting information from the patient. Although communicating with a patient may seem like a simple task, it actually takes communication skills 3 practice and knowledge to communicate with the patient in a manner that encour- ages respect for the healthcare provider and that enables the pharmacist to obtain an accurate and complete history. Some practitioners are able to naturally commu- nicate with patients more effectively, whereas others have difficulty communicat- ing with patients due to a variety of reasons, including their personality, comfort level, and confidence. However, regardless of one’s natural abilities, communica- tion skills and questioning techniques, especially when it comes to communicating with patients, are learned and take time to develop. This chapter examines the most pertinent skills required to conduct a comprehensive medication history. These skills and questioning techniques include: • Active listening • Empathy • Building rapport • Open-ended questions • Closed-ended questions • Leading questions • Silence • “Why” questions • Nonverbal communication cues active Listening The first communication skill to be mastered is listening, specifically active listen- ing. Listening is defined as hearing what is being said, whereas active listening is a dynamic process that includes both hearing what is being said as well as processing and interpreting the words that are spoken (and/or unspoken) to understand the complete message that is being delivered. Whereas listening is a passive process, active listening requires the listener to consciously choose to give the patient atten- tion and concentration that is free of distractions and interruptions, both external and internal. External distractions include ringing telephones, flickering computer screens, and other infringing per- sonal and/or other duties. These external distractions can be avoided by interacting with your patient in a place that is free of such distractions. Internal distractions occur for two major reasons: (1) many matters, unre- lated to the patient in front of you, may occupy your mind and (2) it is difficult 4 chapter 1 / the patient interview to perceive what the patient is saying without tainting his or her message with your personal judgment. The first reason can be addressed by making a conscious effort to concentrate solely on your interaction with the patient. This is more dif- ficult to accomplish than it sounds, but, with practice, turning on the “listening switch” in your mind will become easier. The second reason is more difficult to 1 address, because instinct often leads us to judge or evaluate what the patient is saying based on our own frame of reference. Biases, prejudices, and judgments cloud the message that is being delivered by the patient, which, in turn, affect the patient interaction, and possibly clinical outcomes. For example, as you prepare 2 for a patient who has been referred to you for smoking cessation counseling, you read in several progress notes that the patient “refuses to give up smoking. Therefore, as your patient is talking about reasons why it is difficult for him to quit smoking, your mind is hearing what is being said but is interpreting it as excuses rather than reasons that you may be able to address with the patient to assist him in quitting smoking. One way to overcome internal distractions is by being present in the moment, during your patient visit, addressing your patient’s current concerns without focusing on your preconceived notions. Sympathy is when you feel sorry for the patient but do not feel the same emotions or are not in the same situation, whereas empathy is when you place yourself in your patient’s situation and respond based on either similar personal experiences or through vicarious understanding. When you express empathy, it allows your patient to feel as though you understand his or her unique experience and that you are applying your expertise to the patient as an individual. Empathy can be shown in several ways, and each way will depend upon the partic- ular patient as well as the situation.

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Slow sand filtration due to their ineffectiveness at reducing the smaller particulate organic matter (i generic 40 mg lasix with amex blood pressure and alcohol. On the other hand buy lasix 40 mg low cost prehypertension treatment diet, well operated coagulation based treatment processes are effective at removing particulate matter and reducing dissolved organic carbon. This inorganic fouling is a complex problem related principally but not only to hardness and iron levels in the water, resulting in the accumulation of coatings on quartz sleeves. Hard waters have greater fouling Water Treatment Manual: Disinfection potential particularly from compounds for which solubility decreases with increasing temperature e. Cleaning frequency varies in accordance with the chemistry of the water and the lamp type. The combination of chemical residual and contact time, defined by the Ct value, is an operational surrogate for disinfection efficacy. Common to these standards is the requirement to validate performance using biodosimetry. These factors are specific to the target pathogen and the target inactivation of that pathogen. This is essentially feedback control, with built in allowance for ageing of the lamps over time. A single set point is simpler to implement, but a variable set point is more energy efficient as it can be reduced at low flow (with longer contact time in the reactor). This approach requires a greater complexity, but offers more flexibility in maintaining an appropriate targeted dose in an energy efficient way. Lamps should be replaced when burn time reaches the limit recommended by the supplier. Further practical guidance on the uses and relative merits of both dose monitoring approaches in operation is included in Appendix 2. Cleaning systems are proprietary, and may include chemical and physical mechanisms or a combination of the two, and can be on-line or off-line. Excessive solarization is an indication that a sleeve is close to the end of its useful service life. There is a possibility of compromised performance for a period of time during start up (e. Ultra-violet disinfection as part of a multi-barrier solution for control of Cryptosporidium in drinking water – with case study reference to implemented disinfection solutions in Galway City. Proceedings of the 2nd International Congress on Ultraviolet Technologies, Vienna, Austria, July 9-11. This is consistent with the Drinking Water Safety Plan approach for water supply risk management, outlined below. They were originally outlined in rd the 3 Edition of Guidelines to Drinking Water Quality published by the World Health Organisation in 2004, which states that “The most effective means of consistently ensuring the safety of a drinking-water supply is through the use of a comprehensive risk assessment and risk management approach that encompasses all steps in water supply from catchment to consumer”. By knowing what is in the catchment, it is possible to understand the source water for a works and target treatment effectively. Network operations and customer education will help to prevent deterioration of the delivered water. Identify all the hazards and hazardous events that can affect the safety of a water supply from the catchment, through treatment and distribution to the customers tap. Water Treatment Manual: Disinfection Keep accurate records for audit and justification of outcomes. A common way of ranking risk is through a scoring system which categorises the likelihood and consequence separately, and combining these in a frequency/consequence matrix, Table 8. Alkalinity: The quantitative capacity of water to neutralize an acid; that is, the measure of how much acid can be added to a liquid without causing a significant change in pH. This capacity is caused by the amount of bicarbonate, carbonate, and hydroxide compounds present in the water Alkalinity is not the same as pH because water does not have to be strongly basic (high pH) to have high alkalinity. A flat board or plate, wall, deflector, guide or similar device constructed or placed in flowing water to cause more uniform flow velocities, to absorb energy, and to divert, guide, or agitate water.

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Moreover generic lasix 40 mg with mastercard pomegranate juice blood pressure medication, it is very effective for treating dermal infections caused by susceptible strains of Escherichia coli and Staphylococcus aureus discount 40mg lasix fast delivery blood pressure band, the 2 most common bacteria around the implants. Dosage and Administration: Enrofloxacin is one of the very few drugs we have that can be administered once a day, thereby eliminating the need of injecting the animal multiple times daily. It should be used whenever mild to moderate infections are noticed, and definitely before and after every surgical operation. If possible (if the animal is anesthetized) the dosage can be divided in two injections daily. Cephalothin Description: Cephalothin is a broad‐spectrum antibiotic acting against streptococci, staphylococci, Klebsiella, salmonella. Do not confuse Cephalothin with the regular triple antibiotics (that cannot be applied on the eye). Dosage and Administration: The ointment can be applied to the eye 3‐4 times daily. It enters the cerebrospinal fluid even in the absence of meningeal inflammation, appearing in concentrations about half of those found in the blood. Serious and fatal blood dyscrasias are known to occur after the administration of chloramphenicol. Cleocin Description: Cleocin phosphate Sterile Solution in vials contains Clindamycin phosphate, a water soluble ester of Clindamycin and phosphoric acid. Usage: Clindamycin is an antibiotic used in the treatment of infections caused by susceptible anaerobic bacteria as well as for infections caused by streptococci, staphylococci and pneumococci. Anaerobic bacteria are responsible for certain serious respiratory tract infections, serious skin and soft tissue infections, septicemia. Since Clindamycin does not diffuse adequately into the cerebrospinal fluid, the drug should not be used in the treatment of meningitis. It should be noted that Clindamycin therapy has been associated with severe colitis which may end up being fatal. As an alternative to dosing on a body weight basis, monkeys may be dosed on the basis of square meters body surface: 350 mg/M(squared)/day for serious infections and 450 mg/M(squared)/day for more severe infections. It does not penetrate the blood‐brain barrier, but it diffuses readily into intracellular fluids, and antibacterial activity can be achieved at essentially all the other sites. It can be used for minor streptococcal and staphylococcal infections Usage: Used in the chambers or systemically, according to the veterinarian’s instructions. Erythromycin ethylsuccinate suspensions may be administered without regard to meals in a dosage 10‐20 mg/kg/day in equally divided doses. Genoptic Ointment and Solution (Gentamycin Ophthalmic) Description: Genoptic is a sterile, topical anti‐infective agent for ophthalmic use. Gentamicin sulfate occurs as a white to buff powder and is soluble in water and insoluble in alcohol. Usage: In Vitro gentamicin sulfate is active against many strains of the following microorganisms: Staphylococcus Aureus, Staphylococcus Epidermidis, Streptococcus Pyogenes, Streptococcus Pneumoniae, Enterobacter Aerogenes, Escherichia Coli, Haemophilus Influenzae, Klebsiella Pneumoniae, Neisseria Gonorrhoeae, Pseudomonas Aeruginosa, and Serratia Marcescens. Genoptic ointment and solution are indicated in the topical treatment of ocular bacterial infections including conjunctivitis, keratitis, keratoconjunctivitis, corneal ulcers, blepharitis, blepharoconjunctivitis, acute meibomianitis, and dacryocystitis, caused by susceptible strains of the following microorganisms: Staphylococcus Aureus, Staphylococcus Epidermidis, Streptococcus Pyogenes, Streptococcus Pneumoniae, Enterobacter Aerogenes, Escherichia Coli, Haemophilus Influenzae, Klebsiella Pneumoniae, Neisseria Gonorrhoeae, Pseudomonas Aeruginosa, And Serratia Marcescens. Dosage and Administration: Genoptic solution: Instill one or two drops into the affected eye(s) every four hours. Genoptic ointment: Apply a small amount (about 1/2 inch) to the affected eye two to three times a day. Neosporin Ophthalmic Ointment Description: Neosporin Ophthalmic Ointment (neomycin and polymyxin B sulfates and bacitracin zinc ophthalmic ointment) is a sterile antimicrobial ointment for ophthalmic use. Neomycin sulfate is the sulfate salt of neomycin B and C, which are produced by the growth of Streptomyces Fradiae Waksman (Fam. It has a potency equivalent of not less than 600 mcgm of neomycin standard per mg, calculated on an anhydrous basis. Polymyxin B sulfate is the sulfate salt of polymyxin B1 and B2 which are produced by the growth of Bacillus Polymyxa (Prazmowski) Migula (Fam. It has a potency of not less than 6,000 polymyxin B units per mg, calculated on an anhydrous basis. Bacitracin zinc is the zinc salt of bacitracin, a mixture of related cyclic polypeptides (mainly bacitracin A) produced by the growth of an organism of the Licheniformis group of Bacillus Subtilis var Tracy. Usage: A wide range of antibacterial action is provided by the overlapping spectra of neomycin, polymyxin B sulfate, and bacitracin.

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Major opioid withdrawal is usually treated The profle of the person for whom acamprosate with either an equivalent dose of methadone would be selected is one seeking complete absti- gradually decreased over time discount lasix 40 mg with visa blood pressure 1, or more recently 40mg lasix sale hypertension in children, a nence and who is moderately to highly motivated single dose of 24 mg of buprenorphine. The study found synthetic, long-acting medication used in heroin 29 detoxifcation programs to maintain abstinence psychoactive: Substances or drugs that affect the mind, especially mood, thought, or perception. Many varenicline Chantix people who have been addicted to heroin have bupropion Zyban returned to a productive life because of methadone nortriptyline Aventyl, Pamelor treatment programs. Methadone also is occasion- ally used to provide relief for specifc types of pain. It can be used for both opioid with- containing products is the goal of tobacco cessa- drawal and as a substitute for opioids in long-term tion therapies. Buprenorphine is the frst medication tobacco cessation assist clients with nicotine dependence32 to achieve abstinence by alleviating available to doctors for use in their offce-based practice. At low doses, it acts like methadone and or reducing common nicotine withdrawal symp- toms33 and cravings. Numerous scientifc studies satisfes the dependent person’s need for an opioid to avoid painful withdrawal. It does not provide have shown that it’s easier for individuals to quit the user with the euphoria or rush typically tobacco when supported by a medical or a mental associated with use of other opioids or narcotics. For this reason, recommended At moderate to high doses, it can precipitate treatment strategies incorporate both behavioral withdrawal. Suboxone is buprenorphine combined pharmacotherapy is contraindicated for some with naloxone, a narcotic antagonist31 used to specifc populations (i. They are transdermal nicotine patch, nicotine polacrilex beginning to be more widely used for alcohol gum and lozenge, nicotine nasal spray, and nicotine relapse prevention (see pp. These therapies reduce more commonly used in its injectable form to withdrawal symptoms and cravings by replacing reverse the effects of opioids. It is beginning to be used in its oral form to reduce alcohol craving; it is 32 nicotine dependence: Nicotine dependence is a recognized also beginning to be used in gambling and nicotine mental health disorder that is often overlooked by counselors. This substance use disorder signifcantly reduces the overall quality-of-life and is considered the deadliest yet most preventable disease to be treated. This causes the brain to release noradrenaline and dopamine, which act as stimulants nicotine polacrilex Commit (implicated in mood, memory, and sense of well-being). This agent is tive of the damage caused to nerve cells by some of thought to affect dopamine34 and norepinephrine35 these drugs. Antipsychotics and sedatives are used levels, and blocks nicotinic acetylcholinergic to treat induced psychoses associated with club receptors36, thereby decreasing cravings for drug abuse. Marijuana: Recently, a withdrawal syndrome to The use of bupropion roughly doubles cessation marijuana dependence has been described and rates relative to placebo, and the combination of validated. Medications for treating this syndrome bupropion with the nicotine patch has shown 37 have not been adequately tested. Therefore some clinicians smoking cessation medication and the frst in its have used moderate doses of the older tricyclic class targeting specifcally the neurobiology of antidepressants (e. It reduces the smoker’s to treat withdrawal from marijuana as they also craving for nicotine by binding to nicotine recep- have anticholinergic and sedating qualities but do tors in the brain and thereby reducing withdrawal not cause a high, nor are they abused. A Stimulant intoxication: Agitation, paranoia and daily, uninterrupted dose of disulfram is continued psychosis are treated with antipsychotics, often until the person is in full and mature recovery and combined with benzodiazepines. Stimulant withdrawal: There are no standard Naltrexone in its oral form is usually taken once a effective agents to treat stimulant withdrawal, day but can be taken at a higher dose every second though dopamine-enhancing agents such as or third day. The amantadine, bupropion, and desipramine have injectable form of naltrexone is taken once a month. This area has not Because of the way acamprosate is absorbed, it must been well researched. During the initial 6 weeks of If injected intravenously, buprenorphine will cause therapy, clients should use one lozenge every 1 to 2 opioid withdrawal. This is an advantage for persons who do lozenges in 6 hours or a maximum of 20 lozenges not live near a methadone clinic. The lozenges should be used for up to 12 People should continue to take naltrexone, acam- weeks with no more than 20 lozenges used a day. Generally, for the tion, including the nicotine patch, gum, and frst 3 days of treatment, individuals take 150 mg, lozenge. The approved course of varenicline treatment is 12 weeks; however, an additional 12 weeks of treat- The nicotine patch is available in three strengths ment may increase the likelihood of long-term and a “step-down” approach is used: 21 mg for 6 smoking cessation for some individuals.

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