Geriatrics Rotation VGH 7N Sept 2nd to Oct 2nd
Final Reflection:
During this last week I discharged 3 more of my patients and completed the discharge for the 4th that will now leave early next week. I also continued to monitor for DRP’s and assessed one of my patients who became acutely ill. Using the VIHA intranet antibiotic resource I was able to confirm that the IV Imipenem therapy was appropriate for the antibiotic coverage my patient required for cholecystitis (Enterococcus, E.coli, Klebsiella, Enterobacter). I also did admit one more patient this week and was able to begin solving some of her drug related issues. I think that this week I did accomplish my goal of working more on my process. I also did practice my presentation skills and completed my case presentation (see entries below). Upon review of the last 5 weeks I think that I have learned a tremendous amount and have built a new knowledge base and confidence when it comes to working up patients. I also feel I was able to integrate well into the team and work collaboratively with nurses, physicians, OT’s, PT’s and social work. This ward was a great place to start my clinical rotations!
Final Exam Case:
Today I was given a Case to work up in 2 hours and then present for 1 hour. This was a mock exam to practice for my final residency exam. The patient had surgery earlier this year (CABG, AVR) and a subsequent infection. As well, this patient ended up with Acute and then Chronic Renal Failure from the infection and IV antibiotic given. During the two hours, I started by reviewing the chart to find out some history, and background information, the recent blood pressure trend, weights and chart notes. I then looked in PowerChart to find out recent lab values and reviewed consults. I also interviewed the patient to get a compliance history and a medical history with details regarding therapy used. Finally, I assessed my work up for drug related problems and found about 7 DRP’s. I prioritized the DRP ‘s and then wrote a SOAP note on the most important one. I then presented my patient to my preceptor Cathy:
1-Reason for visit/Brief history
2-Compliance assessment
3-List of medical problems
4-Review of Systems (ROS) with medications integrated (discussed NESA and highlighted where DRP’s existed)
5-Discussed each DRP
6-Reviewed top DRP SOAP note (including monitoring plan)
7-Feedback from preceptor (discussed patient thoroughly, found correct DRP’s and prioritized appropriately, should include more in monitoring plan [who will do monitoring and for how long])
I really appreciated being given this opportunity to practice for my exam. I also felt that I gained confidence to know that I can thoroughly work up a patient in 2 hours and find the significant DRP’s. This experience really showed me how much I have learned over the past 5 weeks and proved to me that my process is more concrete! It was also a great way to integrate the knowledge I had just learned at my last two therapeutic sessions on acute and chronic renal failure.
What I hope to accomplish in my last week:
During this last week I hope to finish discharging 3-4 more of my patients (total of 7 -8) and continue to monitor and solve drug related issues with those that are not ready to go home yet. This past week was very busy and I found it was hard to continue to work on my process when there was so many urgent issues coming up each day. I hope this week to admit one more patient and practice the full process from gathering lab values and history to interviewing the patient and develping/resolving DRP’s. I also hope to practice my presentation skills (talking slow, providing thorough information etc.) this week by presenting to nursing students on monitoring drug therapy and presenting my first case presentation!
Midpoint Reflections:
Since arriving on the ward I have noticed a big improvement in my confidence in gathering information, presenting my patients to my preceptor and assessing for drug related problems. I think that I am more thorough when looking up the patients history on Pharmanet, Powerchart and when interviewing. I have also noticed that I am following up with my patients more effectively. I have made a system where I start the morning by checking powerchart, the mar, interdisciplinary notes and then look for new orders and consults. By doing this each day I can assess for new DRP’s and problems that have come up during the night and continue to follow up on old DRP’s to make sure they are resolved.
In addition, I have now discharged 3 patients, I feel that I am getting quicker at making the medication calendars and preparing the home medication prescriptions. I also enjoyed doing my first “SAM” trial this week and learned a lot from this! On initiation of the trial the nurse and I thought the patient was going to be successful with blisterpaks and knew how to dose warfarin by blood test results. The patient was successful for the first part of day one. By the second day, I learned that the patient required prompting from the nurse and did not remember the previous conversation we had about warfarin dosing and what was in the blisterpak. I think that this was a great learning experience and made me realize that it is best to counsel days before discharge. In this case, I started to counsel 3 days before discharge and obvioulsy needed the time to follow up a few times to check for clarity. After this experience I will be sure to start the medication counseling with my patients as we go along and not all at the end if possible.
My goals for the last 2 weeks are to monitor Heather’s patients and prepare them for discharge. I will also work hard to become more comfortable handling this increase in workload and continue to try and investigate DRP’s for my new admissions with less preceptor prompting!
1/2 Way Summary:
This last two weeks have been really fun! I have enjoyed practicing my interview skills and making SOAP notes. I have noticed a big improvement this week with how confident and concise I am. I have solved DRP’s related to delirium and tapering risperidone, UTI prophylaxis with cranberry capsules and compliance. I also have numerous DRP’s I am monitroing for next week in regards to dermatitis, anticoagulation and incontinence. I have also discharged one patient which included making a medication calendar, counseling the patient on new medications and counseling on how to dose warfarin. I also made a warfarin sheet for the physician to see the INR trend and most recent doses. I plan to help discharge two more patients next week and have one new admission interview to do on Monday. This week I hope to increase my patient workload and get use to managing a greater number of patients at once. I am also going to continue to work on my thought process (SOAP notes and DRP’s) and skills for gathering information so I can make a more comprehensive history for each of my patients. Looking forward to this week!
Journal Club
Sept 9th at VGH: Discussed ACTIVE A, ACTIVE W and ACTIVE I trials. This presentation focused on ACTIVE A and discussed the benefits and risks of using Clopidogrel + ASA versus ASA alone in Atrial Fibrillation patients who could/would not take Warfarin. This trial showed that the combination did have a greater benefit then ASA alone but that the increase in bleeding risk did not make this option favourable.
Therapeutic Discussions
Sept 8th Delirium: Today we discussed delirium in relation to a patient I am currently assessing. We discussed risk factors such as: infections, surgery, electrolyte imbalances and disorientation (no glasses or hearing aids). We also discussed drugs that could potentially worsen delirium such as benzodiazepines and narcotics. Finally we discussed how to treat delirium and how to taper medications as the patient improves.
Sept 10th Dementia: In today’s discussion we talked about the numerous types of dementia including: vascular, lewy body and parkinsonian dementia. We also talked about cholinesterase inhibitor therapy and the use of antipsychotics in this type of patient.
Sept 11th Osteoporosis: Today we discussed Forteo and Zoledronic acid. The two articles we reviewed both showed a decrease in fractures. The benefits of Zoledronic acid include: once yearly infusion over three years, decreases all three kinds of fractures and good for patient with poor memory or gerd. The drawbacks include: unknown long term effects after 3 years, infusion related reactions and risk of osteonecrosis of the jaw. Forteo is also a good medication because it can build and repair the patients bone. However, this medication is very expensive and requires daily injections; therefore, it is not the most reasonable choice in my current geriatric patients. Further drawbacks include that this medication is limited to 18 mo of therapy because of the risk of osteosarcoma and when therapy is completed further treatment is required with a bisphosphonate to maintain the new bone structure.
Sept 14th Incontinence: Today we discussed the main types of incontinence. The two kinds are patients that can’t urinate and have post void residual (PVR) and those that urinate too much and are dribbling or leaking. There are many different kinds of medications for men and women. For men some medications can decrease the size of the prostate and allow urine to pass through with less difficulty and decrease the PVR (eg. tamsulosin). Other medications for men and women can either relax the bladder to allow it to fill (eg. detrol) and not continuely empty or contract the bladder to help the patient fully void (urecholine).
Sept 17th Parkinsons: Today we discussed parkinsons disease in relation to one of my new patients. We talked about parkinsons being caused by a lack of dopamine in the brain and damage to the brain cells. We also talked about the different classes of medications and how they work. For example, L-dopa is a precursor to dopamine that is adminstered at the same time as carbidopa, which blocks its metabolism before it enters the brain. In addition, we talked about depression and psychosis therapies in parkinson’s patients and how psychiatric medications can worsen parkinsons symptoms.
Presentation Sept 15th “Medications for Osteoporosis”:
Sept 29th Medication Monitoring: Today I presented to the nursing students on how to monitor certain medications. We talked about Warfarin and what an INR is measuring. We also discussed how to monitor for bleeding. We also talked about antidepressants and how long it takes to see an effect and some of the side effects to watch out for in the elderly. I also stressed the importance of ”starting low and going slow” when initiating new therapy in the elderly. Finally, we discussed medications that can increase the risk of an elderly patient falling and how to reduce this risk. Today’s presentation went well, I think that I talked slowly and took pauses to ask if there were any questions or points needing clarification and improved from the last time I presented!
Presentation Sept 30th Final Case Mrs FT:
Today I presented my first case presentation. I think that my presenting skills are improving. I felt that I didn’t talk as fast as I did during my first journal club. I also felt more comfortable with my slides and had practiced them numerous times. I think that for my next presentation I would like to be more comfortable with the evidence surrounding my case presentation; I got asked some questions about other medications in osteporosis (estrogen) and was not able to answer the question as well as I would have liked to. I think that I know for next time the types of questions that could be asked beyond what I present.
