Clinical skills Flashcards
(26 cards)
What is the difference between pre-term, term and post-term neonates?
pre-term: < 37 weeks gestation
term: 37 to 42 weeks gestation
post-term: ≥ 42 weeks gestation
What are neonates, infants, children and adolescents?
neonate: up to 28 days
infant: 28 days up to 24 months
child: 2 years up to 12 years
adolescents: 12 to 17 years
What are the 5 different ways of dosing for children?
Dosing by total body weight (TBW)
Dosing by specific age ranges
Dosing by body surface area (in m2)
Corrected gestational age for preterm neonates
Dosing by Ideal Body Weight (IBW)
What is corrected gestational age?
Corrected gestational age is the neonate’s total age expressed in weeks from the start of the pregnancy
For example, a 3 week old baby born at 27 weeks gestation is treated as having a corrected gestational age of 30 weeks
How do you calculate a child’s BSA?
Calculate weight in kilograms
Calculate height in centimeters
Multiply height by weight and divide by 3600
Take the square root of answer
How do you calculate ideal body weight?
IBW = BMI50 x height (m2)
where BMI50 represents the 50th centile of a BMI chart, which is the ideal BMI for their height, age and gender.
What are the absorption changes in pregnancy?
Medication may not stay down long enough to be absorbed if hyperemesis
Timing of medication can be changed or may be given with an anti-emetic
Progesterone (and other pregnancy hormones) slows gastric emptying so can cause decreased absorption and changes in bioavailability
What are the distribution changes during pregnancy?
- Plasma volume increases
- Total body water increases by 8 litres
- Decreased plasma albumin concentration so free levels of drug may rise.
- Regional blood flow changes
What are the metabolism and elimination changes during pregnancy?
- Progesterone can also affect hepatic enzyme changes
- Higher cardiac output
- GFR and renal plasma flow also increased
What are the concerns surrounding valproate in pregnancy?
Around 1 in 10 babies will have a birth defect
Physical effects:
- Spina bifida
- Cleft lip and palate
- Malformations of the limbs, heart, kidney, urinary tract and sexual organs.
Developmental effects:
- Late development
- Lower intelligence
- Poor speech and language skills
- Memory problems.
How do we monitor pregnant patients?
1st at 8-14 weeks (the ‘dating’ scan)
2nd between 18-21 weeks (‘anomaly’ or ’mid-pregnancy’ scan)
Blood tests
Blood pressure
Urine tests – protein and infection
Monitoring for sign of gestational diabetes – oral glucose tolerance test (OGTT)
Which 4 common conditions must be taken care of during pregnancy?
Diabetes – glucose tolerance decreases
More frequent blood glucose monitoring
More frequent doses of insulin or metformin
Epilepsy – many antiepileptic drugs are teratogenic e.g. valproate, carbamazepine, lamotrigine
Also increased risk of folate deficiency
High blood pressure – also risk of pre-eclampsia. May need to switch BP medication during pregnancy (labetalol, nifedipine and methyldopa considered safe)
Mental health problems – many drugs are not ideal in pregnancy but would need to make a risk benefit assessment
What are the three main concerns for medications while breastfeeding?
- The amount of drug or active metabolite of the drug delivered to the infant (dependent on the pharmacokinetic characteristics of the drug in the mother)
- The efficiency of absorption, distribution, and elimination of the drug by the infant (infant pharmacokinetics)
- The nature of the effect of the drug on the infant (pharmacodynamic properties of the drug in the infant).
When does transfer of care occur?
- change of care setting
- handover between HCPs
- specialist referrals
- patient transport
How can transfer of care occur?
- SystmOne
- Letters/Email
- Phone call
- PharmOutcomes
- Verbal
What are the 5 risks of poor transfer of care?
- confusion/misinterpretation
- Inappropriate monitoring
- Medication errors
- Delayed follow up
- Hospital re-admission
What are the ways of preventing poor transfer of care?
- patient/family counselling
- referral to community
- direct update to community
- GP pharmacist to review all discharge letters
What is medical consent?
Consent to treatment is the principle that a person must give permissionbefore they receive any type of medical treatment, testor examination
- Given on the basis of an explanation from a clinician
- For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.
- Voluntary: Consent that is given freely without pressure from others
- Informed: The person must be given all information in terms of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment doesn’t go ahead/is not taken
What is capacity?
Capacity means the ability to use and understand information to make a specific decision, and communicate any decision made
A person lacks capacity if their mind is impaired or disturbed in some way and this means the person is unable to make a decision at the time when it is needed
Incapacity can be transient, temporary or permanent
Capacity in health and social care is defined and legislated for under the Mental Capacity Act (2005)
When may a person lack capacity?
E.g. post-stroke, severe mental illness, intoxication, unconscious
If an adult lacks capacity to consent, a decision on whether to go ahead with the treatment has to be made by the health professionals treating them
The treatment must be necessary during the time when the person lacks capacity
Must be in best interests
How do you determine a persons best interests?
Can you wait until capcity is regained?
Involve the person in the decision as much as possible
- Identify issues the person would take into account themselves, including religious or moral beliefs.
- Consider views the person expressed previously and insight of close relatives or friends
- If a person is felt to lack capacity, and there’s no one to help make decisions, an independent mental capacity advocate (IMCA) must be consulted
When must capacity cases be seen by the courts?
If there’s serious doubt about an incapacitated person’s best interests, HCPs can refer the case to the Court of Protection. This is the legal body that oversees the operation of the Mental Capacity Act (2005)
Situations that must always be referred to the courts:
- sterilisation for contraceptive purposes
- donation of organs or regenerative tissue, such as bone marrow
- withdrawal of nutrition and hydration from a person who’s in a permanentvegetative state
What is lasting power of attorney (LPA)?
A person can arrange for someone, often a close family member, to have lastingpower of attorney (LPA) if they anticipate loss of capacity to make important decisions at a later stage.
Someone with LPA can make decisions about health but the person can choose to specify in advance certain treatments they want the person with LPA to refuse for them by drawing up the procedures and treatments that a person refuses to undergo and will be respected
What are the exceptions when treatment may be performed without consent?
Emergency treatment life-saving treatment while they’re incapacitated
Additional emergencyprocedure required during an operation
Person with a severe mental health condition lacks capacity to consent to the treatment of their mental health
Person requireshospital treatmentfor a severe mental health condition, but self-harmed or attempted suicide while competent and is refusing treatment
Person is a risk to public health as a result of rabies, cholera orTB
Person is severely ill and living in unhygienic conditions can be taken to a place of care without their consent
