Self Care

Define self care.

An action taken by an individual to optimise his or her health &wellbeing

* self treating minor ailments

what conditions can be treated as minor ailment?

* headache
* cough
* bacterial eye infection
* fungal nail infection
* weight loss
* strains and sprains
* eczema
* travel sickness

what cant be treated as minor ailments?

* asthma
* high blood pressure

why might patients choose to go GP instead of community pharmacy?

* Booking & waiting for a GP appointment
* Patients don’t understand the role of a pharmacist and are worried that the illness is serious.
* Tradition paradigm–must see a doctor.
* If get a prescription–no need to pay for the medicines

why might patient go pharmacy instead of GP?

* No need for an appointment
* No consultation fee
* Convenien- A lot of pharmacy in an area and open for longer hours, Open 7 days a week
* Confidential–No records are made, therefore patients can speak about a private matter, and they can get usefulinformation.
* Aware of availability of OTC medicines.
* Aware of advice and expertise available from pharmacists
* Be in control of what they are taking–medicine
* Understand that what they have is a “minor condition” eg: headache, cold and fever.

how many packs of otc medicines sold each year?

958 million

what are thee most popular categories?

Cough, cold,analgesics(painkiller),skin conditions.

How many GP consultations/ / yr are for minor ailments?

57 million

how myth does it cost nhs if those patients GO TO A&E?

£124

how myth does it cost nhs if those patients GO TO GP SURGERY?

£43- 160.

how myth does it cost nhs if those patients PHONE NHS DIRECT?

£16

how much does public spend?

£0- £3.50 avg

outline an overview of the conversation pharmacist should have.

* Question to gain PH- patient history.
* Listen fully to responses
* Diagnose the condition
* Suggest treatment options – advice on administration
* OR Refer – to whom, why and how urgently
* Monitoring

how do patients present at pharmacy?

* request by named med
* request by symptoms

outline process if patient presents by medicine name.

* have they had this condition/ medicine before
* find product and remind of: dose, warnings, contraindications etc.
* check patient understanding.
* check ‘ is this still alright for you?’
* non drug advice
* remind to read leaflet
* when to seek medical advise/ return to you.

outline procedure if patient presents with symptoms.

* use questioning framework
* listen to patient and make a decision
* explain ur decision to aptient
* select medicine and explain choice dose and warnings
* check patient understanding and re explain
* non drug advice and follow up

OR
* refer to appropriate hcp, explain reason and urgency

OR
* non drug advice only

what does WWHAM stand for?

* WHO IS IT FOR?
* WHAT ARE THE SYMPTOMS?
* HOW LONG HAVE YOU HAD THEM?
* what ACTION have you taken
* what MEDICATION are you taking?

what does OPQRST stand for?

O- onset, when did it start, gradual/sudden

P- provoke, what makes it worse/ better

Q- quality, describe symptoms, steady/ change

R- region/radiate, point to where it hurts most.

S- severity, how would u rate ur discomfort?

T- time, when did symptoms start/ had them before?

define QuEST/ SCHOLAR MAC

Quickly+ accurately assess patient

* Symptoms
* Characteristics
* History
* Onset
* Location
* Aggravating factors
* Remitting factors- what makes it worse
* MAC- medications, allergies, coexisting conditions

Establish if patient here for self care

Suggest appropriate self care strategies- med/ nma

Teach patient- med, action, administration, adverse affect

outline AS METHOD

A- age/ appearance

S- self or someone else?

M- medication?

E-extra meds?

T- time persisting

H- history?

O-other symptoms

D- danger symptoms

define communication.

Process of exchange of information between two or more people with the goal of getting a message across.

Why are good communication skills essential when supporting patients with their self-care needs?

* ensure they say everything efficeintly and accurately
* trusted to give right info and be empathetic

describe the % of communication etc

* 7% of communication is how we speak
* 38%- intonation and voice
* over 50 is body language- facial expression, posture and arm and hands movement

disadvantages of questioning frameworks

* all info on patient isnt gathered so further qs will need to be asked.
* also patient doesnt like info being dumped on them
* WWHAM- not a free flowing convo, patient wont know how to take.

define open questions

* question that encourages convo, allows to gain more info about patient condition
* starts with: what who why how when

define closed questions

* can be answer with Y/N
* doesnt require much involvement from customer- can i help you?
* common: do yk how to take med?

how to use both Qs

1. ask open q to first understand condition- eg what are ur symptoms atm
2. then probe w closed qs to narrow down condtion eg when u swallow does it hurt?

examples of non verbal communication/ body language.

* ways of talking
* posture
* appearance
* head movements
* hand movements
* eye movements
* facial expression
* body contact
* closeness
* sounds

how should pharmacists adapt their behavior when with patient?

* matching and mirroring
* adopt the body posture of other person
* match facial expression and body movement
* pick up tempo of how theyre speaking
* if theyre casual, using slang etc, do the same

what are the general warning signs/ symptoms?

* loss of consciousness and/or recent severe injury
* loss of appetite- patient not eating
* unexplained weight loss/ bruising
* difficulty swallowing
* blood loss from nose, mouth, anus or ear
* breathlessness
* any swelling/ lumps of any size, including joints
* severe pain in chest, abdomen and head/or ears
* long lasting or repeated period of high temp
* yellow or green phlegm
* vaginal/urinary tract symptoms to do with pain/discharge

what is referral procedure?

Depending on situation:


1. Call 999, stay with patient
2. Send patient to A&E in own transport
3. Phone GP, make urgent appointment
4. Ask patient to make routine appointment ?
5. Ask patient to come back to you

Keep a record of your action on their PMR

define gingivitis

* mild form of gum inflammation that eventially leads to periodontitis- gum disease
* mostly cuased by bacteria build up in dentral plaque
* reversible

How does gingivitis progress?

* Normal build up of plaque each day
* Normal brushing should remove each day

But

* Bacteria produces tartar if built up over a few days
* Sticks to teeth holding bacteria close
* Enzymes and toxins released cause inflammation in gingiva (gum)
* Over years mild damage results in a pocket forming between tooth and gum
* Then tooth root erodes and tooth comes loose

signs and symptoms of gingivitis- 5

* inflammation of gum
* swollen and red
* bleeds easily on mild trauma(brushing)
* plaque visibility
* halitosis- foul taste in mouth, difficulty eating, pain

extra info on halitosis

* more likely in periodontitis
* bad breath
* signpost to dentis because nothing community pharm can do for them

how many people experience some degree of gingivitis

50-90%

what groups are at increased risk

– Poor nutrition

– Ineffective oral hygiene

– Pregnancy- hormone levels rise

– Diabetes - if poorly controlled

– Smoking - effects blood flow

– Immunocompromised

– Age

– Drugs causing dry mouth- allows bacteria to group eg antidepressants/ antihistamines

– Stress

– Local factors- tooth positioning

questioning technique for gingivitis

1. cofnrim symptoms
2. bleeding? with or without trauma- rbushign
* if no trauma bleeding- liekly to be periodontitis so refer
3. toothbrushing technique- too vigorous gums bleed
4. other meds?
* warfarins/heparins, nsaids- blood thinning
* phenytoin side effect is gum hypertrophy- gingival enlargement GUM

what conditions have similar symptoms- differential diagnosis?

* Oral malignancy
* Herpetic gingivostomatitis (viral)- more common in Children, fever/malaise/pain
* Desquamative gingivitis – White and red areas/bullae in mucosa
* Bleeding disorder – Platelet disorder, vascular conditions
* Gum hypertrophy – drugs ADR, hormonal changes
* Allergic reaction
* Denture-associated trauma or candidiasis

gingivitis management- non drug advice

* Advise regular review with dentist or hygienist
* Identify risk factors and manage
* Advise on oral hygiene
* Brush teeth for 2 mins twice daily
* Replace brushes every 1-3 months
* Brushes with small head with medium texture bristles
* Use fluoride-containing toothpaste
* use electric toothbrush as it reaches more areas
* daily interdental cleaning before brushing
* Interdental brushes
* Dental floss or tape
* Mouthwash not routinely recommended unless signs of inflammation
* Bleeding is common so do not stop

OTC treatment for gingivitis.

* firstly it is advised by dentist/hygienist.
* Oral hygiene – Tooth cleaning (scale and polish)
* Mouthwashes

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what mouthwashes are usually used?

1. Chlorhexidine gluconate mouthwash

* Corsodyl or eludril
* 10ml bd
* Staining teeth and tongue brown with prolonged use


2. Hexetidine mouthwash

* Oraldene
* 15ml bd-tds

summarise periodontitis

* Involves supporting tissues around teeth
* Largely irreversible tissue damage
* Slowly progressive
* Tissue and bone damage, tooth loosens

what is dry mouth? - other name?

* Xerostomia
* Subjective complaint of dryness in mouth
* Can cause significant reduction in quality of life
* Problem with saliva quantity and quality

dry mouth symptoms and signs- 11

1. Dry, sticky feeling in mouth or throat
2. Insufficient saliva
3. Saliva feels thick or stringy
4. Rough, dry tongue
5. Sore throat
6. Halitosis
7. Difficulty swallowing, chewing or talking
8. Signs of dryness – cracked lips, sores, split skin at corners of mouth
9. Burning sensation in mouth
10. Altered sense of taste
11. Oral infection in mouth

why do we need saliva?

* Protects, lubricates and cleanses oral mucosa
* Aids chewing, swallowing and talking
* Protects teeth against decay
* Protects mouth, teeth, throat from infection
* Supports and facilitates sense of taste

what are the causes of dry mouth?- 10

1. Medication
2. Salivary gland disease
3. Poor oral intake e.g. dysphagia( difficulty swallowing)
4. Radiation therapy (damages salivary glands)
5. Nerve damage e.g. surgery
6. Dehydration (kidney failure, uncontrolled diabetes)
7. Psychogenic e.g. stress, depression, anxiety
8. Specific conditions e.g. sarcoidosis, Sjogren’s syndrome - as they prevent body to generate fluid.
9. Mouth breathing
10. Idiopathic- no known cause.

what are the long term effects of dry mouth?- 15

1. Dental caries - tooth decay
2. Oral candidiasis - infection
3. Infection of major salivary glands (usually parotid)
4. Dysgeusia (altered taste sensation e.g. metallic)
5. Dysosmia (altered sense of smell)
6. Halitosis
7. Oral dysesthesia (burning or tingling sensation in mouth)
8. Thick or ropey saliva
9. Mucosa appears dry
10. Dysphagia (difficulty swallowing and chewing)
11. Fissured tongue
12. Difficulty wearing dentures
13. Mouth soreness
14. Dry, sore, cracked lips and angles of mouth
15. Thirst

what is non drug treatment for dry mouth?

* Manage underlying cause if possible
* Sipping or spraying water frequently (or cold unsweetened drinks)
* Sucking on ice cubes/lollies
* Sugar-free boiled sweets, gum, pastilles or mints
* Rubbing petroleum jelly e.g. Vaseline on lips or watersoluble lubricant e.g. KY Jelly
* Pineapple chunks?
* Avoiding mouth breathing
* Avoiding caffeine, alcohol, tobacco = dehydration
* Using a humidifier at home

what types of drug treatments are available for dry mouth?

* artificial saliva substitutes
* saliva stimulants

how does artificial saliva substitutes work?

* can improve symptoms
* acts as aritifical saliva- mucin based, carboxymethylcellylose- based
* sprays, gels, pastilles
* medical devices- often seen on dental prescriptions
* dose prn- when required
* Helps supplement saliva’s natural defences
* Soothes and protects oral tissues against minor irritations and burning sensations
* Helps maintain oral environment and provides protection against dry mouth

what preparations are available for medicines?- diff ACBS categories- artificial saliva

* Biotene Oralbalance Saliva Replacement Gel
* Xerotin oral spray
* bioXtra gel
* Glandosane aerosol spray
* Saliveze oral spray

what is a saliva stimulant?

* Increases rate of salivary flow (usually local stimulation of glands)
* Only useful if some remaining detectable salivary function

examples of saliva stimulants

* Organic acids (ascorbic acid, malic acid) – SST ® tablets
* sugar free chewing gum- no strong evidence it improves symptoms just as effective as artificial saliva
* sugar free mints
* salivix pastilles(maltitol)- not ACBS approved, can buy.
* parasympathomimetic drugs:


1. pilocarpine HCL (POM)
2. 5mg tds to minimise side effects
3. doesnt always work
4. given to those who have radiation for head/neck cancers and Sjogrens syndrome

describe the epidemiology of headaches

* most common symptom reported in general pop- lifetime prevalence of more than 90%
* most common neurological reason for going a and e
* most will self manage, still common for primary care consultation
* higher in women than men

what is pain?

* subjective emotional symptom
* hard to define
* defined as: unpleasnt sensory or emotional experience associated with potential tissue damage.
* acute vs chronic(> 3 months/ beyond expected time)

what are the 4 main classifications of pain?

1. nociceptive- stimulation of specific pain receptors
2. somatic-musculoskeletal pain
3. visceral- internal organs
4. neuropathic- peripheral or cns

what is a classified primary headache

* no underlying pathology- cause
* more common- over 90% OTC
* migraine, tension headache or cluster

what is a classified secondary headache

* has underlying pathology
* origin may be trauma or a injury, infectious, neoplastic, vascular or drug induced or psychiatric
* requires referral

what question to ask for those who present with a headache?

* Location and spread of pain?
* Speed of onset?
* Duration? – If headache does not improve or resolve over 1-2 weeks, refer (unless tension headache)
* Intermittent or constant
* Frequency? – Present on awakening may be serious but need further history
* Severity? (pain scale) – If progressively getting worse or non-responsive, refer
* other symptoms
* aggravating or relieving factors
* impact on daily living
* social, emotional and psychological impacts
* medication

what are the 5 locations of pain.

1. Frontal:Idiopathic headache, sinusitis, nasal congestion
2. Occipital(back of head):Tension, anxiety (especially if pain radiates over the top and side of head)
3. Hemicranial (unilateral–one side):Migraine, sinusitis (can spread to both sides later), shingles (one day before orwhen rash appears), trigeminal neuralgia (one side of face)
4. Orbital (behind/around eyes):sinusitis, migraine, shingles, pain from within eyes–glaucoma, eye disease
5. Temporal (temples onthe side of head):Temporal arterities (over 50Yrs + sensitivity to touch on temples)

where do sinus headaches tend to act?

pain is behind browbone and or cheekbones

where do cluster headaches act

pain is in and around one eye

where do tension headaches act

pain is like a band squeezing the head

where do migraines act?

pain, nausea and visual changes are typical of classic form

what is sudden pain indicative of? - description of pain

* haemorrhage
* feels like a blow to the head
* migraine develops over a longer period

what is throbbing/ pounding pain indicative of

* a vascular cause- vasodilation caused by fever/migraine

what is constant/ nagging pain indicative of?

* tension headache
* if it gets worse may be more serious, eg bleeding

what is moderate- severe pain indicative of?

migraine

pain location of tension headache

bilateral

pain location of migraine, with- or without- aura

unilateral or bilateral

pain location of cluster headache

unilateral - around the eye, above eye and along side of head/face

what is the pain quality for tension headache? and intensity?

pressing/ tightening

non pulsating

mild to moderate

what is the pain quality of migraine? and intensity?

pulsating

throbbing or banging in young people aged 12-17

moderate or severe

what is the pain quality of cluster?- and intensity?

variable

can be sharp, boring, burning, throbbing or tightening

severe or very severe

what effect do these headaches have on activities.

tension- not aggravated by routine activities/ daily living

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migraine- aggravated by/ causes avoidance of routine activities/ daily living

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Cluster- restlessness/ religion

what are the other symptoms of the headaches

1. tension- none
2. migraine- sensitivity to light/sound/ nausea/vomitting

* for aura migraine- occur w or w/o headache, develop over 5 mins, last 5-60 mins- symptoms include flickering lights, spots partial loss of vision, sensory symtpoms, pins and neededles and or dpeech disturbance.


3. cluster- on same side as headache:
* red/ watery eye
* nasal congestion/ runny nose
* forehead/ facial sweating
* constricted pupil/ drooping eyelid

duration of tension

30 min- continuous

duration of migraine

* 4-72 hrs in adults
* 1-72 hrs in 12-17 years

duration of cluster

15-180 mins

diagnosis of all the headaches and frequency?

1. episodic tension- type headache-

questions to ask ab other symptoms

1. nausea and vomitting= migraine, meningigitis
2. fever= sinusitis, viral infection
3. nasal congestion= sinusitis, cluster headache
4. insomnia= severe headache
5. visual disturbances= migraine, glaucoma
6. neck stiffness= injury, meningitis
7. rash= meningitis, viral
8. weight loss= cranial areritis, malignancy
9. cns symptoms( loss of coordination, drowsiness, irritability, LOCALISED LESIONS- slurred speech, limb muscle weakness,)
10. tender temples- inflamed temporal arteries, red, congested vessl in temple area- pressure applied to area is painful maybe jaw ache- usually in older people

what are migraines characterised by

* unilateral
* modera- severe throbbing pain

how long does migraine take to bildup?

* minutes to hours
* occurs every few weeks

what are migraines associated with?

* nausea and vomitting
* sensitivity to light and sound

symptoms for with/ without aura

with aura= visual symptoms, sensory speech disturbances

usually disappears within an hour, followed by severe headache lasting 4-72 hrs

what is it called when you can sense a migraine coming

prodromal phase

what is the theory for migraines

related to dilation of blood vessels within or around skull

what are tension headaches characterised by?

bilateral pain, generalised ache, tight band around head spreading to top of head

can be episodic or chronic

what is the theory behind tension headache?

* muscle spasm in neck and scalp/ tension in muscles resulting in constricted capillaries, reducing blood flow= lack of O2

migraine vs tension

characteristics of cluster headache

* severe unilateral pain within and aboce eye and temporal region

what is the occurence of cluster like?

* once every other day to 8 times a day often with circadian rhythm
* can occur at same time of duy and clusters at same time each year

what ssymptoms is cluster headache associated with?

* associated with autonomic symptoms
* eg lacrimation,rhinitis, facial sweating, restlessness or agitation
* refer

what is a chronic daily headache

headache that last longer than 15 days per month

pain appears from morningt o night

varies from ache to dull throb

refer

what headdacche is cuased by too much med and what is the theory

* medication overuse headache
* Secondary headache
* Theory: analgesic overuse causes an increase in number of pain receptors that are switched on, first by pain itself then by increased sensitisation of receptors
* Exaggerated response of receptors that more frequent or potent analgesics do not stop
* Usually taking simple or combination analgesic on >3 days per week

what other secondary headaches exisy>?

1. traction headache- pahtologu causes irritation and stretching of meninges caused by inflammation, tumours and haematomas
2. space- occupying lesions- tumours and cerebral abscesses compress brain tissue against skull= increased intracranial pressure
3. spasm or fatigue of ciliary and periorbital muscles of eye
4. claucoma
5. referred from jaw
6. sinuses
7. shingles affecting scalp or eye
8. hypertension- rarely

how to manage the pain

1. rule out referral
2. remove causative factors
3. water and fresh air can help simple headaches
4. analgesics- check underlying vause, severity and type of pain first
5. chronic/ repeat headaches- migraine or tension give non drug therapy like relaxation- acupuncture, osteopath etc

how to manage medication overuse headache

1. 1/50 experience
2. stop all headache medicines for at least a month
3. symptoms will get worse before they improve
4. be alert of:

\-Triptans, opioids, ergotamines or combination analgesics for at least 10 days per month for over 3 months

– Paracetamol, aspirin or NSAID either alone or in combination for at least 15 days per month for over 3 months

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