Caregiver Training Courses

Caregiver Training Ebooks

The caregiver training e-book gives a training course on how to provideassistance to another person who is ill, disabled or needs help with daily activities. It can also serve as a useful guide to the individuals in the need of help. The product deals in physical, mental, social, and psychological needs and well-being of both the caregivers and the elderly person requiring care. Everyone needs a little help from time to time and while many seniors lean on the friends and family members for support, there may be some instances in which it's necessary to seek additional assistance or long-term care which was why this product was created by the author. This caregiver product is a practical guide created by the author who is an expert in the field. This product embeds in it several training sections in which each section gives detailed information on how to provide assistance to people who are ill, disabled, or aged. This product is a trusted and 100% guarantee to provide the necessary details needed in caring for the physically challenged, aged and ill individuals. The product is also an essential overview of issues from Alzheimer's to diabetes to strokes. Read more here...

Caregiver Training Ebooks Summary


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Administration Of Drugs In The Home

Many times drugs are not administered by the nurse but in the home setting by the patient or family members serving as caregivers. When this is the case, it is important that the patient or caregivers understand the treatment regimen and are given an opportunity to ask questions concerning the drug therapy, such as why the drug was prescribed, how to administer the drug, and adverse reactions of the drug (see Chap. 5 for information concerning patient and family education). The Home Care Checklist Administering Drugs Safely in the Home gives some guidelines to follow when drugs are administered in the home by the patient or caregiver, rather than by the nurse.

Descriptive Goals And Causal Inference

Accepting the goal of accurate measurement, avoiding any consideration of causality, there are still several requirements for the research to be valid and therefore useful. Distortion can arise due to problems in subject selection or participation (selection bias). For example, if women with dementia were cared for in institutional settings to a greater extent than men, perhaps due to lack of availability of a spouse as caregiver, an assessment restricted to those receiving institutional care would generate an inaccurate reflection of the true magnitude of gender differences. Similarly, errors in measuring exposure or disease (misclassi-fication) are detrimental to any conceivable use of the data. If the diagnosis of dementia is in error, whether planning health services or studying etiology, the value of the study is diminished. The ill-defined process of random error also introduces uncertainty in the study results, independent of any concern with etiologic inference. If instead of...

Weight Monitoring for Schizophrenia

Patients with schizophrenia should be given nutritional counseling and recommendations for an exercise regimen, given their propensity for poor dietary habits and sedentary lifestyle. Primary care practitioners, family members, and other caregivers should be alerted to the risk of obesity during treatment with certain novel antipsychotics, as the potential complications of weight gain in patients with schizophrenia can be serious. It is also essential that patients be educated regarding the weight gain liability of their antipsychotic medication to minimize the risks of obesity and its related health consequences. Multiple cases of new-onset diabetes (Wirshing et al. 2001a), hyperlipidemia (Meyer 2001 Wirshing et al. 2001b), and sleep apnea have been reported as potentially associated with antipsy-chotic-related weight gain (Furst et al. 2002), although there may also be effects of certain novel antipsychotics on glucose tolerance and lipids independent of their effects on weight....

The MET as a Logical Approach for Preventing Serious Adverse Events in Hospitalized Patients

And just as lay people cannot be expected to deal with acute illness in the community, junior and inexperienced doctors cannot be expected to reliably deal with life-threatening critical illness in the hospital. Thus, objective, reproducible, and easily measured criteria must be developed to trigger intervention by the MET (Table 8.2). Preset criteria increase the reliability of MET calls, and allow auditing of the appropriateness of the calls and any delays. In addition to being objective and reproducible, the criteria are non-invasive, and thus provide potential benefit with minimal risk of harm. They include familiar and routine nursing vital signs as well as a worried criterion (caregiver worried about patient and wants help) to allow flexibil-

The MET Requires Political Support

Our experience is that if these political processes are dealt with carefully and systematically, all stakeholders will support the new approach. Of course, each stakeholder may come to this realization in his or her own time. Nurturing those wary of the MET response must continue long after other caregivers may have given it strong endorsement.

Markers Of Myocardial Necrosis

The use of cardiac markers in the ED setting is now commonplace and provides additional valuable information to that from the initial ECG, history, and physical examination. For most available markers, the quantitative assay time is 20 min or less, and the overall turnaround time is within 1 to 2 of ordering the test. The development of bedside qualitative assays for various markers or panels of markers promises not only to shorten the overall time to test result, but also to place the testing and result reporting in the hands of the caregivers, a feature that should aid in rapid decision-making in the ED. The use of individual bedside testing assays for cardiac troponin I (cTnI) and tro-ponin T (cTnT) has been studied in several large trials for chest-pain evaluation in the emergency department and for acute ST-segment elevation MI (44-46). In a study of 609 chest pain patients, van Lente and colleagues directly compared bedside qualitative cTnT testing (cut point 0.2 ng mL) with...

Foundations for System Change

Health care marketing strategies have also changed. Health care buyers are working together to get the best value instead of the best cost. For example, the Leapfrog group in the United States has defined system standards and care goals that have prompted providers to alter their approach to care delivery, marketing, and data collection (16-18). Thus, senior health care officials are now attentive to safety as an important indicator of quality of care within a hospital, and a number of agencies in the United States, Australia, and Europe now are showing interest in METs. For example, the Institute for Healthcare Improvement is providing courses on METs, and JCAHO has included information on METs at its national meeting. Both the federal and state governments in Australia are currently sponsoring an evaluation of the MET system. Because safety is a goal for all caregiver organizations, these forces are leading administrators and caregivers to recognize the possible benefit of the MET...

Home Care Checklist

In some situations, narcotic analgesics may be ordered for pain relief using patient-controlled analgesia (PCA). If the patient will be receiving PCA at home, the nurse makes sure to review the following steps with the patient and the caregiver If the patient or caregiver will be responsible for changing the drug cartridge or syringe, the nurse teaches the following steps Gather new syringe with drug (if refrigerated, remove it at least 30 minutes before using). Attach pump specific tubing to the drug. Prime the tubing.

Telephone Value and Appropriateness of the Service

Some physicians are willing to spend large amounts of time on the phone with patients, whereas others rarely speak to patients outside of the exam room, opting instead to have most calls from patients returned by an office staff member. Whatever the protocol of the office, the physician is responsible for care delivered, regardless of whether it is delivered directly or through a member of the staff. In addition, the ability of a specific patient or caregiver to use telephone-based communication should be considered, as should the appropriateness of using the telephone to communicate sensitive clinical information.

Telephone Patient Expectation

The growing frustration among patients regarding an inability to speak to their doctor on the phone only partially results from increased demands on the physician's time and a lack of reimbursement for telephone-based care. A substantial portion of this frustration stems from inadequate expectation management. It is guaranteed that patients or caregivers will want to telephone their doctor at some point, likely when a need arises and stress levels may be high. It is also guaranteed that doctors who spend entire days on the phone providing unreimbursed care to patients will quickly find their practices in financial trouble. The gap between patient expectation and practical limitations must be filled with disclosure and expectation management, preferably done ahead of the telephone ring, and in writing. Physicians are well advised to develop written protocols associated with the appropriate use of the telephone in their practice. These protocols should be used to set patient...

Value and Appropriateness of the Service

The value of the Internet in the patient-physician relationship is only beginning to be quantified. However, it is clear that there are opportunities to enhance communication in a manner that promotes patient understanding as well as increasing communication efficiency. The asynchronous nature of e-mail and websites means that both the clinician and the patient can access and deliver information at a time and place that is convenient for him or her. This can be an important attribute to Internet-based communication, particularly when compared to the interruption and frustration that can be associated with ill-timed telephone calls or telephone tag between physicians and patients. It is also likely that providing patients with graphic instructions, available via websites, and a written record of physician instructions, via e-mail, can enhance the quality of patient understanding and provide an accurate document to which patients and care givers can refer repeatedly. E-mails can also be...

Triggering the Ventilator Expiration

Although NIV is generally perceived as more comfortable for patients than invasive mechanical ventilation, mask (or interface) intolerance remains a major cause of NIV failure 43 . Failure rates range from below 10 to over 40 , despite the best efforts of skilled caregiver staff. Thus, improvements in mask design that enhance comfort and reduce complication rates are needed, with the presumption that they will lead to improved tolerance and reduced NIV failure rates 44 . Leaks create major dysynchrony that the clinician needs to recognize. In case of leaks, attempts to minimize the leaks must be performed and should include readjustment of the mask and decrease of the delivered pressures 45 . Once leaks persist, minimizing their consequences on patient-ventilator interaction becomes important. During PSV, adjustment of the cycling-off criterion or addition of an inspiratory time limit will help in avoiding prolonging the ventilator's inspiration long after the end of the patient's...

The Nature of Teaching Hospitals

Teaching hospitals share the complexities of other health care facilities and large organizations, with the added dimension of a large number of incompletely trained caregivers and perhaps a higher likelihood for error. Errors in teaching hospitals may be augmented because of their typically larger scale and more complex case mix.

Family Work Involvement

Jacquelynne Eccles (1994) argues that women are expected to assume this responsibility because women and men have different Work family mandates. Because men are expected to be breadwinners, they fulfill their family role through successful employment. In contrast, work and family are expected to be separate, and sometimes conflicting, spheres for women. Indeed, interviews with 40 employed and married mothers and fathers of children under 18 revealed that men's definition of good fathers as economic supporters contrasted with women's description of good mothers for whom employment was an added responsibility separate from their primary obligations to family (Simon, 1995). Women's family obligations are expected to encompass household chores and caregiving, activities totally separate from work-related success.

Preadministration Assessment

Before starting therapy for the hospitalized patient, the nurse obtains a complete psychiatric and medical history. With AD, patients often are unable to give a reliable history of their illness. A family member or primary caregiver will be able to verify or give information needed for an accurate assessment. During the time the history is taken, the nurse observes the patient for any behavior patterns that appear to be deviations from normal. Examples of deviations include poor eye contact, failure to answer questions completely, inappropriate answers to questions, a monotone speech pattern, and inappropriate laughter, sadness, or crying. These patients are in varying stages of decline. Display 33-1 identifies the stages of AD and the associated clinical manifestations. The nurse documents the patient's cognitive ability using Display 33-1 as a guide.

Educating the Patient and Family

The patient with AD may understand and comprehend the extent and severity of this disease early on in the disease process, but as cognitive abilities decrease, the nurse will focus on educating the family and major care-giver of the patient. Depending on the degree of cognitive decline, the nurse will discuss the drug regimen with the patient, family member, and or caregiver. It is important for the nurse to accurately evaluate the patient's ability to assume responsibility for taking drugs at home. The administration of drugs to the patient with AD becomes a family responsibility if the outpatient appears to be unable to manage his or her own drug therapy. The nurse explains any adverse reactions that may occur with a specific antipsychotic drug and encourages the caregiver or family members to contact the primary health care provider immediately if a serious drug reaction occurs.

Changing the Existing Culture

An important component of resource management is recognizing the crisis and reliably alerting the team. The UPMC had a system in place for responding to crises for a decade, but it saw limited use while physicians were still being paged urgently and sequentially to the bedside to care for their patients. The institution then started reviewing the incidences of sequential stat pages and reminding the nursing units to use the team response, and the individuals responsible for the delay in team activation were given feedback on their actions. However, the most effective two policies that were implemented were (1) the establishment of calling criteria, and (2) the dissemination of these criteria to the nursing units and other caregiver groups. The result was a significant positive change in MET use, with a corresponding drop in the number of sequential stat pages (6). Obtain key data from chart, caregivers

What Are the Goals and Risks

The caregiver also needs to know the risks and problems with intensive insulin therapy so they can be openly discussed with the patient. Best known is the potential for hypoglycemia. The DCCT reported a threefold increase in severe hypoglycemia, which was defined as requiring aid from someone else, and a threefold increase in hospitalization for hypoglycemia, in patients with HbA c of 7.2 versus 8.9 (1). Several subgroups were at particularly high risk adolescents, males, those without residual c-peptide, and those with a prior history of severe hypoglycemia (11). The most important clinical predictor for high-risk patients is the presence of hypoglycemia unawareness patients report that their reactions have changed so they no longer feel the sweats, shakes, or pounding heart (i.e., loss of the catecholaminergic symptoms) but instead experience

The Origins Of Defences

Anxiety is an inevitable part of life but too much anxiety is disabling. One of the most crucial capacities that we need to acquire early on is how to manage anxiety and other strong affects. Our early experiences with caregivers are crucial to the development of a capacity to regulate our affective experiences. Nowadays the regulation of affects is understood to be first mediated by the parental figures the child interacts with in

Current Status Of The Use Of Mri In The Diagnosis And Therapy Of Stroke

Up to 85 of all strokes are of ischemic origin and mostly due to blockage of a cerebral artery by a blood clot 1 . The target for most therapeutic interventions for focal ischemia is ischemic tissue that can respond to treatment and is not irreversibly injured. Such tissue must be distinguished from nonsalvageable ischemic tissue, which has evolved to a state, in which recovery is no longer possible. The characterization of potentially reversible vs. irreversible loss of function is based on the concept of the ischemic penumbra 2 . Until recently only PET and SPECT imaging could approximately define ischemia and penumbra thresholds. This is, however, not feasible for caregivers in a broad population, where diagnostic imaging in an acute setting is confined to CT and MRI imaging.

Origins of the Met A Solution to a Real Problem

Problems with establishing proper care were found to exist at multiple levels nurses were not calling physicians for patients with abnormal vital signs or changes in sensorium physicians did not fully evaluate these abnormalities when they were contacted ICU consultants were not called in routinely, and senior level or consulting ICU caregivers did not obtain routine

Concerns Over Implementing a Medical Emergency Team

One can understand, if not sympathize with, departments that are reluctant to accept an extra- or multi-departmental group caring for patients in their service. Yet interdepartmental cooperation frequently occurs at bedside, where the caregiving team is happy to relinquish significant portions of a patient's care management to a cardiologist, nephrologist, surgeon, or oncologist. Indeed, the latter specialties possess certain types of technology, protocols, and detailed knowledge of pathophysiology that can be key to the optimal care management and survival of a patient. In the context of specific organ-based derangements, it is rational to seek this type of support so why not for critical illness as well Intensive care may be poorly understood by other physicians, and mainly in narrow, stereotypic roles such as the use of mechanical ventilation, invasive monitoring, and hemodynamic support. In addition, the appearances of illnesses that permeate multiple systems do not present clear...

Focus on Delivery of Care to Patients Home

Institutional medicine developed fully in the 20th century, but in previous centuries almost all ailments were cared for at home. Now we face the shift to home care once again. This trend is driven by the pressure on medical cost reduction and availability of teleinformatic solutions improving home care quality. The patients usually prefer to stay at home than in a hospital ward. It is reasonable to let them remain in the environment they perceive as friendly and assuring. However, the quality of health services and safety of the patient must be impaired. Home telecare depends strongly on patient empowerment which is presently an obvious objective of successful long-term care. The majority of home visits of health professionals may be substituted by telecare. The estimations made in the USA indicate that the cost of a home telecare visit is one third of that of an on-site visit. On-site visits are related to considerable overhead costs dependent on transportation use and time of the...

Management Plans Developed in eHealth Environment

The first-generation solutions for home-based treatment and care were based on old hospital-centred solutions with minimal integration giving minor support to the caregiver as well as medical professionals. Second-generation solutions are built on specific needs for specialist medical professionals with minimal focus on collaboration between levels and professions in the health chain (Figure 11-2). The second-generation systems are based on a point-to-point solution with telephone broadband connection between patient home and a control center with medical professionals specialized on giving care to patients with many needs. In order to support the WHO model 74 for care of chronic patients there is a need for the development of third-generation solutions focusing on collaboration between health levels and professions as well as supporting the local caregiver (e.g. patient relative). In Figure 11-3 a suggestion for an overall solution supporting this is described. Important issues...

Patient Doctor Relationships

The patient's attitude toward the caregiver may reflect their anxiety, how they are feeling, their confusion, distress, even anger, or their reaction to treatment. Help them by establishing and building the relationship. Encourage them to know and understand why they are seeing you and what the treatment is likely to be. Your attitude to the patient is crucial. We have a right to be respected this means being told about the condition in understandable terms and to have a second opinion if needed. Many patients are experts in their own nonmedical, fields and will usually respond positively when a physician or other caregiver takes the trouble to treat them as intelligent beings with a vested interest in what is going on.

Experiencing Various Tests And Treatments For the Rest of Their Lives Adjusting to Long Term Care

It is possible that some patients may reject treatment at some stage (compare with adolescent diabetes mellitus patients), or they may not be aware of its continuing necessity, so it is important that caregivers secure the patient's cooperation with and understanding of the ongoing nature of the tests and treatment as early in the process as possible.

Vehicles for Unconscious Communication

Slade (2000) suggests that the application of Main's work translates in a focus on the structure of language, syntax and discourse, which may be understood to unconsciously represent the dynamics of an individual's early object relationships. Indeed, Fonagy's (2001) work suggests that secure or reflective patterns of language and thought indicate the presence of an internalised other who can contemplate or contain the breadth and complexity of the child's needs and feelings. In this sense, the breaks, incoherencies and contradictions observed in the narratives of insecurely attached adults are said to imply a break in the caregiver's capacity to respond to the child's need for care and comfort. Listening to the structure of the patient's narrative sensitises us to the quality of his early experiences of attachment and how this might be translated into the patient's current relationships. An important task in therapy then becomes that of reflecting on, and mentalising, those aspects of...

The Phallocentric View

The phallocentric view is best represented by Freud's account of the Oedipus Complex. According to Freud (1933 1964), in early childhood both boys and girls recognize their mother as their primary caregiver and, because she fulfills their basic needs, they love and feel attached to her. As children move from the anal to the phallic stage of psychosexual development, their erogenous zone shifts to their genitalia. Their primary source of need satisfaction, the mother, then becomes an object of sexual desire.

Food Assistance And Nutrition Education Programs

Knowledge of age-appropriate feeding practices and good nutrition concepts cannot be implemented unless a caregiver has access to food or to financial resources to buy food. A number or programs have been created over the years to assist families in obtaining foods, many developed by the US Department of Agriculture (USDA). Table 14-1 describes USDA-directed programs for children. In addition, many state and local agencies, neighborhood health centers, and local schools and universities offer programs and services to promote the nutritional health of children.

Preoperative Assessment Pituitary Adenoma Surgery

Nonfunctioning pituitary tumor, 81, 84 preoperative assessment, 115 radiation therapy planning, 207, 208 Rathke's cleft cyst, 257, 258 Coping, pituitary disease patients, caregiver facilitation, 307 infertility, 305, 306 job loss, 306 caregiver support strategies, 291, 292, 308

Object Relations Approaches II The British Independent School

Although Klein's interest lay in the individual's relationships to objects, she was nevertheless primarily focused on primitive instinctual impulses and their phantasised effects upon internal objects. She was less interested in how real people might have contributed to the phantasies and, more generally, to psychopathology. The rise of object-relations theories postKlein was supported by a shift of interest towards developmental issues and, particularly, a recognition of the impact of the early relationship between the baby and the mother or other primary caregiver.

Algorithms or Sliding Scales

A common element of intensive insulin programs is insulin algorithms short-term adjustments in doses for variable activity, diet, etc. Unlike pattern management, the dose changes are made only once, to cover the event. Each patient's algorithms are unique, and are based on the patient's and caregiver's identification of diet, exercise, and other habits that cause the blood glucose values to deviate from the usual range, then designing and validating diet and or insulin fixes. Algorithms are operative when patients tell you, I play basketball two

Root Cause Analysis RCA

In essence, one must convince caregivers that their current workflow is wrong and a new, untested work plan is better. With data from adverse events leading to the creation of a MET, and workflow changes directed at preventing repeats of actual near-death events, it is much more likely to change mindsets and practices. For instance, an RCA about an empty oxygen cylinder almost being used during patient transport might result in an action to purchase cylinders with a more direct indication of contents (indicator valves). However the same problem that caused a near-death event from hypoxemia would more highly motivate not only the bedside caregivers, but also the administrators who oversee purchasing choices and materials management. Furthermore, procurement committees will likely accept the additional cost if there was more than 1 event. Because METs tend to find similar types of errors, creating lists of similar events is not difficult. For example, if the organization had 5...

Assisted Mechanical Ventilation

Esophageal Balloon Dynamic Auto Peep

With pressure support, the inspiratory flow rate depends on the amount of delivered pressure, the mechanical properties of the respiratory system and the inspiratory muscle effort 24 . Cycling-off is flow dependent in pressure support ventilation, and varies according to the machine. Some ventilators cycle-off at 25 of peak inspiratory flow, others cycle-off at low levels of flow (for instance 5 of peak inspiratory flow), others allow free manipulation of cycling-off. Also, pres-surization ramp differs among ventilators, and some machines allow for caregiver setting of this variable. Both, cycling-off and pressurization ramp may profoundly influence patient-ventilator interactions. Generally speaking, the less steep pressure ramps increase patient work of breathing 25 , whereas cycling-off at very low flow levels may profoundly influence breathing pattern, in particular when patients have a long respiratory system time constant 26 . Pressure support levels are adjusted, at the...

The Transference Relationship

At the outset, many prospective patients are likely to turn to us with a mixture of fear and hope that activates latent phantasies regarding authority figures and caregivers, phantasies into which we will be unconsciously fitted. The patients most difficult to treat are those with persecutory phantasies that shape virtually all aspects of their mind as they relate to the world with phantasies organised around controlling, tormenting or rejecting the object as a defence against the risk of becoming the victim of phantasised retaliatory attacks.

Specific Inanimate And Animate Vectors

The epidemiology of resistant microorganisms in the hospital environment involves the complex interplay of antibiotic use the clustering of ill, immunocompromised patients and both animate and inanimate vehicles and reservoirs. While the precise origin of these microbes is often not identified, it is clear that excessive antibiotic use creates the environment that promotes their amplification, with such use being greatest in the intensive care unit. As antibiotic use may vary widely between different specialties within the same institution, it should not surprise us that different resistance patterns, and different species of resistant organisms, may be seen in differing areas of the hospital. Under the selection pressure of excessive antibiotic use resistant organisms may reach quite high levels in reservoirs such as the gastrointestinal tract, the urinary tract, and the mucous membranes. Patients so colonized may be totally unrecognized by their care givers, allowing for the heavy...

Gerontologie Alert

The nurse gives metformin two or three times a day with meals. If the patient has not experienced a response in 4 weeks using the maximum dose of metformin, the primary care giver may add an oral sulfonylurea while continuing metformin at the maximum dose. Glucophage XR (metformin extended release) is administered once daily with the evening meal.

Infantile Nonepileptic Events

A wide variety of events can mimic seizures in the infant. Within the first 2 years of life, while the central nervous system is maturing, children can exhibit different behaviors and events that are physiologically normal for that age, although may appear paroxysmal and unusual to care-givers. In addition, well-described paroxysmal disorders can also mimic epileptic events. The remainder of this chapter reviews spells that occur in 1-month to 2-year-old infants that may mimic myoclonic, clonic, or tonic seizures, as well as events marked by a loss of consciousness, abnormal eye movements, and unusual behaviors (Table 6.3). The following nonepileptic events are categorized as events with excessive movements, events that mimic tonic seizures, and events of abnormal eye movements. In addition, the nonepileptic events described for neonates (apnea, jit-teriness, benign neonatal sleep myoclonus, pathologic nonepileptic myoclonus, and hyperex-plexia), may also occur in infants.

Excludes encopresis NOS R15 F982 Feeding disorder of infancy and childhood

A feeding disorder of varying manifestations usually specific to infancy and early childhood. It generally involves food refusal and extreme faddiness in the presence of an adequate food supply, a reasonably competent caregiver, and the absence of organic disease. There may or may not be associated rumination (repeated regurgitation without nausea or gastrointestinal illness).

Longterm applications

FDA is often called upon to provide estimates of the amount of underreporting to the Agency of device-related adverse events. Few robust estimates exist. A figure of less than 1 (of the true adverse event rate) is often quoted, based on a General Accounting Office report of device adverse events occurring in hospitals 13 . More recent, rigorous data suggest underreporting rates as high as 40-fold, when comparing ICD-9 discharge codes to voluntary incident reporting within hospitals 14 . Using NEISS data, one might be able to compare, for example, estimates of the number of life-threatening device-related events (by device type) to the number reported by caregivers to the FDA. Such efforts can help target intervention efforts by FDA to enhance timely reporting of certain device-related events of interest.

Conclusions One Psychoanalysis or Many19

Freudian and object-relational approaches are often contrasted. Freud's theories underwent multiple revisions, yet throughout he remained loyal to the centrality of the drives viewing them as the fundamental motivational force in development. As far as Freud was concerned, it was the baby's helplessness that resulted in the attachment to caregiving figures. The attachment was thus understood as developing secondarily in response to the baby's oral needs (e.g. feeding) that the caregivers could satisfy. Nevertheless, it is apparent while reading Freud that he never ignored the importance of relationships in shaping the development of the individual. His views on transference, identification and the development of the superego, to name but a few, highlight his awareness of the influence of the ''other'' on the developing mind.20

Centers for Disease Control and Prevention National Center for Health Statistics

A national probability sample survey of home health and hospice care agencies, this survey was first conducted by NHCS in 1992 and repeated in 1993 and 1994. The survey was fielded again in 1996, 1998, and most recently in 2000. The NHHCS was implemented as a result of changing trends in alternative sources of care for individuals and families facing long-term and end-of-life healthcare needs. In 2000, the sample consisted of about 1800 home health and hospice agencies and a sample of six current patient records and six discharged patient records from those agencies. The survey includes all types of agencies that provided home health and hospice care, regardless of whether they were Medicare or Medicaid. The data collected depict both the characteristics of these healthcare providers and the people they serve. Agency and patient items include, for example type of ownership and affiliation Medicare and Medicaid certification patient demographics and functional status diagnoses services...

The Structure of Hospitals

The traditional care provision model is one largely dependent on the knowledge and memory of the caregiver. It is an intensively human and social process, with all the potential this model creates for adverse events. Understanding this concept is an initial but fundamental step in being able to modify the system and the culture. The basis of the personal and human dimension of the doctor-patient and the nurse-patient relationships needs to be appreciated. These relationships have evolved over more than 2 millennia of medical care in the West and are based on the construct of a deep trust and professional commitment that operate at an individual level. This is a powerful, emotionally charged model but one with which patients are

Viiicontrol Measures

The NLVs are readily transmitted in institutional settings. Procedures such as minimizing contact between sick and healthy persons and thorough decontamination of surfaces in contact with vomitus and feces may prevent further spread. Caregivers should wear gloves and gowns if contamination with fecal material is possible. Gloves should be replaced or disinfected frequently. Soiled laundry must be handled carefully. Care should be taken not to have chambermaid, laundry, patient care, or janitorial staff assigned kitchen duties within these institutions.


The science of measuring safety is gradually maturing. Some measures of safety lend themselves to rates, while others do not. We have described an approach for organizations to answer the question, Are patients safer We also have summarized the issues regarding measuring and improving reliability, and provided a framework for improving safety. With these measures, we defer to the wisdom of caregivers and administrators to identify and mitigate safety concerns, but also attempt to provide a framework to assist the caregiver with safety efforts. The need to improve quality and safety is significant, and hospitals are learning how to accomplish this goal. METs are grounded in safety theory and offer the promise to reduce patient harm. We hope practical strategies such as those proposed here help move safety and quality efforts forward.

Deficient Knowledge

Adverse reactions, and the times and method of administration. At times, the patient may have a lack of knowledge about the disease condition. In these situations, the nurse addresses the specific deficient knowledge (ie, adverse reactions, disease process, method of administration, and so on) in words that the patient can understand. It is important for the nurse to first determine what information the patient is lacking and then plan a teaching session that directly pertains to the specific area of need. (See Chap. 5 for more information on patient education.) If the patient lacks the cognitive ability to learn the information concerning self-administration of drugs, then one or more of the caregivers should be taught to administer the proper treatment regimen.


Noncompliance is defined as behavior of the patient or caregiver that fails to coincide with the therapeutic plan agreed on by the patient and the health care provider. Patients are noncompliant for various reasons, such as a lack of information about the drug, the reason the drug is prescribed, or the expected or therapeutic results. Noncompliance also can be the result of anxiety or bothersome side effects. The nurse can relieve anxiety by allowing the patient to express feelings or concerns, by actively listening as the patient verbalizes feelings, and by providing information so that the patient can be fully informed about the drug. Many patients have a tendency to discontinue use of the drug once the symptoms have been relieved. It is important to emphasize the importance of completing the prescribed course of therapy. For example, failure to complete a course of antibiotic therapy may result in recurrence of the infection. To combat noncompliance the nurse finds out the exact...


Anxiety is a vague uneasiness or apprehension that manifests itself in varying degrees from expressions of concern regarding drug regimen to total lack of compliance with the drug regimen. When anxiety is high, the ability to focus on details is reduced. If the patient or caregiver is given information concerning the medication regimen during a high anxiety state, the patient may not remember the information. This could lead to noncompliance. The anxiety experienced during drug administration depends on the severity of the illness, the occurrence of adverse reactions, and the knowledge level of the patient. Anxiety is decreased with understanding of the therapeutic regimen. To decrease anxiety before discussing the treatment regimen with the patient, the nurse takes time to talk with and actively

Cognitive Domain

The cognitive domain refers to intellectual activities such as thought, recall, decision making, and drawing conclusions. In this domain the patient uses previous experiences, prior knowledge, and perceptions to give meaning to new information or to modify previous thinking. The nurse makes use of the patient's cognitive abilities when information is given to the patient or caregivers about the disease process, medication regimen, and adverse reactions. The patient uses the cognitive domain to process the information, ask questions, and make decisions.


An overview of psychoanalysis would be incomplete, and all the poorer, without consideration of the contributions of attachment theory. Early Freudian and Kleinian thinking were dominated by a psychology of absence. Attachment theorists and, more broadly, those psychoanalyti-cally oriented developmental researchers have contributed a much-needed ''psychology of presence'' (Stern, 2000). Developmental research has devoted close attention to the quality of the child-caregiver bond showing its implications for the child's development of affect regulation, self-esteem, interpersonal functioning and overall mental health. Unlike many object-relations theorists, for example, Winnicott who retained Freud's emphasis on sexual and aggressive drives and phantasies, Bowlby's attachment theory focused on the affective bond in close interpersonal relationships. He emphasised the baby's need to develop and sustain close relationships, thereby supplanting the importance of aggressive and libidinal...

High Risk Patients

Prior to embarking on a public education campaign, the NHAAP targeted high risk patients for education by the medical community (23,24). This group continues to be an important patient population for education about early recognition and response to acute MI. Over 12 million patients in the United States have a history of an MI, angina pec-toris, or both, divided approximately evenly between males and females. People who survive the acute stage of a heart attack have a chance of illness and death that is 1.5-15 times higher than that of the general population, depending on their sex and clinical outcomes. The risk of another heart attack, sudden death, angina pectoris, heart failure, and stroke, for both men and women in this group, is substantial (1). Within 6 yr after a recognized heart attack, 18 of men and 35 of women will have another heart attack. Furthermore, 7 of men and 6 of women will experience sudden death (1). It is recommended that these high-risk patients receive...


Uncovering a change in the severity, frequency, or number of adverse events by examining complaint files or by searching the MDR database for similar experience with other products. There maybe spontaneous reports from patients, professionals, caregivers, and even reports in the news media, that can guide the company in assessing PM issues. The manufacturer and regulatory agencies should work together to develop the most comprehensive, least burdensome method of accomplishing the ongoing task of protecting the public health after a product is marketed.

Clinical issues

Pain failure to recognize and appropriately manage pain is not only a breach of the standard of care but is also grounds for allegations of abuse and requests for punitive damages. Allegations of elder abuse are very common when caregivers believe that pain is not being responsibly treated.

Family Work Effects

We have seen that women shoulder a disproportionate share of domestic responsibilities in terms of household chores and caregiving contributions. Although assuming many roles may lead to overload and role conflict at times, it also is possible for multiple role holders to derive benefits from their many and varied responsibilities. The critical role that family-work involvement plays in understanding women's work focuses on the assumption that women's family commitments interfere with their full participation in the workplace. We already have seen that people expect that workers, mostly women, with heavy family obligations will be less productive employees (Janman, 1989). Indeed, one justification for the wage gap is that women voluntarily pursue lower paying occupations that are more compatible with children's schedules. However, an analysis of the occupations in which women dominate finds these to be no more compatible with family responsibilities than other occupations (Glass,...

Receptive Culture

Even if there is leadership and commitment, the MET system will fail in the absence of a receptive culture. If the hospital has an internal culture of unit versus unit antagonism, if it operates in specialty silos with little communication among groups of practitioners, if caregivers and their needs, agendas, or goals are allowed to take precedence over the patient's needs,

Social Development

The initial phase of social development typically consists of attachment, a positive, close emotional bond with a particular individual. That individual often is the primary caregiver for the infant, and the relationship that develops between the child and the caregiver appears to be a function of the interactions they experience. Indeed, the child's reaction to the caregiver is as important in the establishment of the relationship as are the caregiver's responses to the child. During the first year of life, the child's link to the caregiver strengthens to the point where separation anxiety may be displayed when the caregiver leaves the child. This does not mean that the child will suffer from such separations research evidence indicated no significant developmental handicaps for children who were placed in high-quality day care while their parents worked, and in some cases there were many positive effects.

Self Psychology

Kohut argued that narcissistic needs persist throughout life. He suggested that the development of narcissism has its own developmental path and that caregiving figures (i.e. objects) serve special functions. He emphasised the role of empathy in the development of the self, underscoring his belief that the goal of human maturation involves differentiation within empathic relationships. The term selfobject was used to describe the mirroring function that other people perform for the self. Selfobjects can perhaps be best understood as representing functions such as soothing or validating rather than people as such. According to Kohut, we need selfobjects in our environment throughout our life to assist us in our emotional survival. The second form of transference, namely, the idealising transference, refers to a situation in which the patient experiences the therapist as an all powerful parental figure whose presence is necessary in order to feel soothed. Kohut argued that an important...

Mutative Exchanges

Development of coherent internal working models of relationships is tied to the experience of participation in coherent forms of parent-child dialogue. Such dialogue is characterised by the quality of the caregiver's openness to the state of mind of the child. In such interactions, the child's affective or motive states are recognised and elaborated so that the child is helped in regulating her affective experience. The parent provides scaffolding (Lyons-Ruth, 1999) to the child's emotional experience.

The Ideal Marker

An ideal marker of cardiac injury should be both cardiac-specific and have zero blood concentration in the absence of myocardial injury. It should become elevated in the serum soon after the onset of an episode of chest pain to allow the detection of high-risk patients as early as possible and should remain elevated for many hours to allow detection in patients who delay in seeking evaluation. Persistent elevation of a marker for several days could aid in diagnosis and risk stratification of patients with periodic symptoms or those presenting to the ED well after the episode that prompted evaluation. The ideal cardiac marker assay would be inexpensive, have rapid in-laboratory and reporting turnaround times, or be available at the bedside, where ordering, testing, and results feedback would be in the hands of the caregivers.

Pulmonary Toilet

The severity and quantity of secretions in patients with COPD can range from non-existent to severe, especially in individuals with a bron-chitic component to their disease. The pulmonary rehabilitation program can provide a great deal of benefit to help manage the secretions in the pre- and postoperative settings. The techniques of secretion management can often be taught to the individual and to caregivers, to be carried on after completion of the pulmonary rehabilitation program. The techniques of chest physical therapy are well described in other sources and will not be reviewed in detail here. They include percussion, postural drainage, and can also include suctioning and insufflation exsufflation in selected patients (42,43). Of course, any increase in sputum production or change in sputum quality should be treated aggressively to prevent a severe pulmonary infection. The role of respiratory muscle training has not been established to be definitively useful, although this...


Rheumatic disease affects the ability to perform regular activities of daily life, such as child care, cleaning, personal hygiene, and sports. For many women, loss of the valued roles of care giver and nurturer leads to a decline in self-worth. Patients should be reassured that decreases in activity levels are normal, as is feeling frustrated with one's level of ability. Patients must be encouraged to find new ways to perform tasks, to find new leisure activities, or to redefine roles at home and work.


At present, thrombolytic therapy is still underutilized. A major problem of the approach is that relatively few candidates meet the clinical and time criteria. Educating the general public to regard stroke as a treatable emergency and training emergency caregivers in the use of thrombolysis can decrease these problems but demands a continuous effort. Healthcare institutions should be made aware of the potential in long-term cost savings, once stroke management is optimized and thrombolysis is more widely available. Patients and their relatives should be informed not only about the hazards of thrombolytic therapy, but also about its potential benefits and thus the risks of not adopting it.


The main objective of blood glucose measurements in diabetics is achieving optimum therapy. The monitoring process is based on sampling blood glucose levels carried out by the patient or the caregiver. Blood glucose measurements usually should be accompanied by blood pressure monitoring. The measurements are entered into a personal computer connected to the Internet and sent to the monitoring centre. In early solutions standard telephone lines were used for data transmission. In this scenario patient involvement in the measurements is necessary. Another option relies on the use of transcutaneous biosensors making automatic measurements of blood glucose levels and then transmitting the results to a personal computer linked to the Internet. Web-based systems with telemonitoring designed for use by patients and health professionals bring new advantages like long-term management options, access to electronic patient record and decision support 65 .

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