Toprol XL

Mario J. Garcia, MD, FACC, FACP

  • Professor of Medicine and Radiology
  • Chief, Division of Cardiology
  • Montefiore Medical Center-Albert Einstein College of Medicine Cardiology
  • Bronx, New York

Human contact and reassuring words reduce the panic of the severely injured person and aid in dispelling fear of the unknown blood pressure medication overdose death order toprol xl 50mg line. That is blood pressure medication causes cough order cheap toprol xl on line, the patient should be touched blood pressure medication dehydration buy toprol xl 50 mg low cost, called by name lipo 6 arrhythmia order toprol xl 100mg online, and given an explanation of every procedure that is performed prehypertension 131 toprol xl 50 mg visa. As the patient regains consciousness blood pressure chart online purchase 25mg toprol xl visa, the nurse should orient the patient by stating his or her name, the date, and the location. This basic information should be provided repeatedly, as needed, in a reassuring way. Allowing the family to stay with the patient, when possible, also helps allay their anxieties. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing. Measures to help family members cope with sudden death are presented in Chart 71-2. During these stages, family members are encouraged to recognize and talk about their feelings of anxiety. Although denial is an ego-defense mechanism that protects one from recognizing painful and disturbing aspects of reality, prolonged denial is not encouraged or supported. The family must be prepared for the reality of what has happened and what may come. Expressions of remorse and guilt may be heard, with family members accusing themselves (or each other) of negligence or minor omissions. Family members are urged to adherence to transmission-based precautions for patients who are potentially infectious is crucial. Chart 71-2 Helping Family Members Cope With Sudden Death Providing Holistic Care Sudden illness or trauma is a stress to physiologic and psychological homeostasis that requires physiologic and psychological healing. Patients and families experiencing sudden injury or illness often are overwhelmed by anxiety because they have not had time to adapt to the crisis. They experience real and terrifying fear of death, mutilation, immobilization, and other assaults on their personal identity and body integrity. When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis. The stages begin with anxiety and progress through denial, remorse and guilt, anger, grief, and reconciliation. The initial goal for the patient and family is anxiety reduction, a prerequisite to recovering the ability to cope. Possible nursing diagnoses include anxiety related to uncertain potential outcomes of the illness or trauma and ineffective individual coping related to acute situational crisis. In addition to anxiety, possible nursing diagnoses for the family include anticipatory grieving and alterations in family processes related to acute situational crises. Reacting and responding to the patient in a warm manner promotes a sense of security. Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. Encourage the family to view the body if they wish; this action helps to integrate the loss. Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the emergency department. Expressions of anger, common in crisis situations, are a way of handling anxiety and fear. Anger is frequently directed at the patient, but it is also often expressed toward the physician, the nurse, or admitting personnel. The therapeutic approach is to allow the anger to be ventilated, then assist the family to identify their feelings of frustration. The key nursing intervention is to help family members work through their grief and to support their coping mechanisms, letting them know that it is normal and acceptable for them to cry, feel pain, and express loss. The hospital chaplain and social services staff both serve as invaluable members of the team when assisting families to work through their grief. In fact, patients in this age group account for more than 99 million visits to emergency facilities each year (see Chart 71-1). Elderly patients typically arrive with one or more presenting conditions involving the skin, cardiovascular system, or abdomen. Nonspecific symptoms, such as weakness and fatigue, episodes of falling, incontinence, and change in mental status, may be manifestations of acute, potentially life-threatening illness in the elderly person. The older patient may have fewer sources of social and financial support in addition to frail health. The nurse should assess the psychosocial resources of the patient (and of the caregiver, if necessary) and anticipate discharge needs. Referrals for support services (eg, to the social service department or a gerontologic nurse specialist) may be necessary. Discharge Planning Before discharge, instructions for continuing care are given to the patient and the family or significant others. All instructions should be given not only verbally but also in writing, so that the patient can refer to them later. If they are not available in the language that the patient needs, an interpreter should be used. Instructions should include information about prescribed medications, treatments, diet, activity, and when to contact a health care provider or schedule follow-up appointments. It is imperative that instructions are written legibly, use simple language, and are clear in their teaching. When providing discharge instructions, the nurse also considers any special needs the patient may have related to hearing or visual deficits. Principles of Emergency Care By definition, emergency care is care that must be rendered without delay. A basic and widely used system uses three categories: emergent, urgent, and non-urgent (Berner, 2001). Emergent patients have the highest priority-their conditions are life threatening, and they must be seen immediately. Urgent patients have serious health problems, but not immediately lifethreatening ones; they must be seen within 1 hour. Non-urgent patients have episodic illnesses that can be addressed within 24 hours without increased morbidity (Berner, 2001). Triage is an advanced skill; emergency nurses spend many hours learning to classify different illnesses and injuries to ensure Community Services Before discharge, some patients require the services of a social worker to help them meet continuing health care needs. For patients and families who cannot provide care at home, community agencies (eg, Home Care Nursing Services, Visiting Nurse Association) may be contacted before discharge to arrange services. Collaborative protocols are developed and used by the triage nurse based on his or her level of experience. Also, nurses in the triage area collect crucial initial data: vital signs and history, neurologic assessment findings, and diagnostic data if necessary. Of course, all answers are documented for reference by other health care providers. Is the patient currently taking any medications, especially hormones, insulin, digitalis, anticoagulants Once the patient has been assessed, stabilized, and tested, appropriate medical and nursing diagnoses are formulated, initial important treatment is started, and plans for the proper disposition of the patient are made. Many emergent and urgent conditions and priority emergency interventions are discussed in detail in the remaining sections of this chapter. Airway Obstruction Acute upper airway obstruction is a life-threatening medical emergency. If the airway is completely obstructed, permanent brain damage or death will occur within 3 to 5 minutes secondary to hypoxia. Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest. Routine hospital triage directs all available resources to the patients who are most critically ill, regardless of potential outcome. In field triage (or hospital triage during a disaster), scarce resources must be used to benefit the most people possible. Refer to Chapter 72 for a complete discussion of triage in mass casualty situations. Pathophysiology Upper airway obstruction has a number of causes, including aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns. In adults, aspiration of a bolus of meat is the most common cause of airway obstruction. In children, small toys, buttons, coins, and other objects are commonly aspirated in addition to food. Peritonsillar abscesses, epiglottitis, and other acute infectious processes of the posterior pharynx can result in airway obstruction. A systematic approach to effectively establishing and treating health priorities is the primary survey/secondary survey approach. Assessment and Diagnostic Findings Assessment of the patient who has a foreign object occluding the airway may involve simply asking the person whether he or she is choking and requires help. If the person is unconscious, inspection of the oropharynx may reveal the offending object. Nursing staff involved in the care of elderly patients must be aware of the symptoms of upper airway obstruction and be skillful in performing the Heimlich maneuver. Typically, the victim with a foreign body airway obstruction cannot speak, breathe, or cough. The patient may clutch the neck between the thumb and fingers (universal distress signal). If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The victim is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. These measures provide oxygen to the brain, heart, and other vital organs until definitive medical treatment can restore and support normal heart and ventilatory activity. Endotracheal intubation is indicated for the following reasons: (1) to establish an airway for patients who cannot be adequately ventilated with an oropharyngeal airway, (2) to bypass an upper airway obstruction, (3) to prevent aspiration, (4) to permit connection of the patient to a resuscitation bag or mechanical ventilator, and (5) to facilitate the removal of tracheobronchial secretions. Because the procedure requires skill, endotracheal intubation is performed only by those who have had extensive training. These include physicians, nurse anesthetists, respiratory therapists, flight nurses, and nurse practitioners. When the tube is inserted into the trachea, it functions like an endotracheal tube. This could effectively provide for ventilation through forced air by way of the larynx. The smaller balloon is inflated with 15 mL of air and can effectively occlude the trachea if placed there. Breath sounds are auscultated to make sure that the oropharyngeal cuff does not obstruct the glottis. Patients can be ventilated through either port of the tube, depending on its placement. This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after an allergic reaction), hemorrhage into neck tissue, or obstruction of the larynx. After these maneuvers are performed, the patient is assessed for breathing by watching for chest movement and listening and feeling for air movement. In such a case, nursing diagnoses would include ineffective airway clearance due to obstruction of the tongue, object, or fluids (blood, saliva). The nursing diagnosis may also be ineffective breathing pattern due to obstruction or injury. If the patient is lying face down, the body is turned as a unit so that the head, shoulders, and torso move simultaneously with no twisting. The fingers of the other hand are placed under the bony part of the lower jaw near the chin and lifted up. The chin and the teeth are brought forward almost to occlusion to support the jaw. This is a safe approach to opening the airway of a victim with suspected neck injury because it can be accomplished without extending the neck. This type of airway pre- Hemorrhage Only a few conditions, such as obstructed airway or a sucking wound of the chest, take precedence over the immediate control of hemorrhage. Stopping bleeding is essential to the care and survival of patients in an emergency or disaster situation. Hemorrhage that results in the reduction of circulating blood volume is a primary cause of shock. Minor bleeding, which is usually venous, generally stops spontaneously unless the patient has a bleeding disorder or has been taking anticoagulants.

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When changing dressings and emptying wound drainage devices hypertension 16090 trusted 100mg toprol xl, aseptic technique is essential hypertension 1 and 2 buy toprol xl without prescription. Prophylactic warfarin arrhythmia consultants purchase toprol xl cheap online, adjusted-dose heparin blood pressure chart heart rate buy toprol xl 25mg mastercard, or low-molecular-weight heparin (eg lower blood pressure quickly naturally best toprol xl 50mg, enoxaparin sodium) may be prescribed hypertension 5 mg order toprol xl 25mg fast delivery. Convalescence and rehabilitation take place at home or in a nonacute care setting. The nurse teaches the patient and the family to recognize complications that must be reported promptly to the orthopedic surgeon. The patient gradually resumes physical activities and adheres to weight-bearing limits. If the patient has a cast or other immobilizing device, family members should be instructed about how to assist the patient in a way that is safe for the patient and for the family member (eg, using proper body mechanics when lifting the patient). The nurse discusses recovery and health promotion, emphasizing a healthy lifestyle and diet. Continuing Care If special equipment or home modifications are needed for safe care at home, they must be obtained before the patient is discharged home. The nurse, physical therapist, and social worker can assist the patient and family in identifying their needs and in getting ready to care for the patient at home. Frequently, home health nursing and home physical therapy are part of the discharge plan of care. These referrals provide resources and help the patient and the family cope with the demands of care during convalescence and rehabilitation. The nurse can explore problems that the patient and family identify during the home care visit. Regular medical follow-up care after discharge needs to be arranged (Chart 67-10). Critical Thinking Exercises You are working in the emergency department of a community hospital. Early this afternoon, an elderly patient who had fallen and broken her right forearm was treated with closed reduction and casting. She was sent home and was told she could call the emergency department if she had any questions or concerns. She has been home for about 7 hours and is calling because she is experiencing extreme pain in her hand and does not know what to do. You are providing postoperative care to two patients who had elective hip replacements. A 48-year-old patient with multiple trauma is placed in balanced skeletal traction to treat his midshaft femoral fracture until his condition is stable for surgical management of the fracture. She complains that her elastic stockings feel tight and hot and asks you to remove them. Improving outcomes in elective orthopaedic surgery: A guide for nurses and total joint arthroplasty patients. Deep-vein thrombosis prevention in orthopaedic patients: Affecting outcomes through interdisciplinary education. Total joint arthroplasty: A comparison of postacute settings on patient functional outcomes. Relationships among self-efficacy, outcome expectancy, and postoperative behaviors in total joint replacement patients. The relationship between multidisciplinary discharge outcomes and functional status after total hip replacement. Use the nursing process as a framework for care of the patient with low back pain. Describe the rehabilitation and health education needs of the patient with low back pain. Describe conditions of the upper extremities and nursing care of the patient undergoing surgery of the hand or wrist. Use the nursing process as a framework for care of the patient undergoing foot surgery. Explain the pathophysiology, pathogenesis, prevention, and management of osteoporosis. Use the nursing process as a framework for care of the patient with osteomyelitis. The limitations imposed on the patient are severe, and the economic cost, in terms of loss of productivity, medical expenses, and other costs that are not compensated, is in the billions of dollars. M Chapter 68 Management of Patients With Musculoskeletal Disorders 2047 Clinical Manifestations the patient complains of either acute back pain or chronic back pain (lasting more than 3 months without improvement) and fatigue. The patient may report pain radiating down the leg, which is known as radiculopathy or sciatica and which suggests nerve root involvement. Physical examination may disclose paravertebral muscle spasm (greatly increased muscle tone of the back postural muscles) with a loss of the normal lumbar curve and possible spinal deformity. Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, osteoarthritis of the spine, spinal stenosis, intervertebral disk problems, and unequal leg length. Older patients may experience back pain associated with osteoporotic vertebral fractures or bone metastasis. Other causes include kidney disorders, pelvic problems, retroperitoneal tumors, abdominal aneurysms, and psychosomatic problems. In addition, obesity, stress, and occasionally depression may contribute to low back pain. Back pain due to musculoskeletal disorders usually is aggravated by activity, whereas pain due to other conditions is not. Patients with chronic low back pain may develop a dependence on alcohol or analgesics in an attempt to cope with and self-treat the pain. Assessment and Diagnostic Findings the Agency for Heath Care Policy and Research developed guidelines for assessment and management of acute low back pain (Bigos et al. These safe, conservative, and cost-effective guidelines have reduced the use of noneffective therapeutic interventions, including prolonged bed rest. The initial evaluation of acute low back pain includes a focused history and physical examination, including general observation of the patient, back examination, and neurologic testing (reflexes, sensory impairment, straight-leg raising, muscle strength, and muscle atrophy). The findings suggest either nonspecific back symptoms or potentially serious problems, such as sciatica, spine fracture, cancer, infection, or rapidly progressing neurologic deficit. If the initial examination does not suggest a serious condition, no additional testing is performed during the first 4 weeks of symptoms. The diagnostic procedures described in Chart 68-1 may be indicated for the patient with potentially serious or prolonged low back pain. The nurse prepares the patient for these studies, provides the necessary support during the testing period, and monitors the patient for any adverse responses to the procedures. Pathophysiology the spinal column can be considered as an elastic rod constructed of rigid units (vertebrae) and flexible units (intervertebral disks) held together by complex facet joints, multiple ligaments, and paravertebral muscles. Its unique construction allows for flexibility while providing maximum protection for the spinal cord. Obesity, postural problems, structural problems, and overstretching of the spinal supports may result in back pain. Disk protrusion (herniated nucleus pulposus) or facet joint changes can cause pressure on nerve roots as they leave the spinal canal, which results in pain that radiates along the nerve. Medical Management Most back pain is self-limited and resolves within 4 weeks with analgesics, rest, stress reduction, and relaxation. Based on initial assessment findings, the patient is reassured that the assessment indicates that the back pain is not due to a serious condition. Management focuses on relief of pain and discomfort, activity modification, and patient education. Nonprescription analgesics (acetaminophen, ibuprofen) are usually effective in achieving pain relief. In the absence of symptoms of disease (radiculopathy of the roots of spinal nerves), manipulation may be helpful. Other physical modalities have no proven efficacy in treating acute low back pain. They include traction, massage, diathermy, ultrasound, cutaneous laser treatment, biofeedback, and transcutaneous electrical nerve stimulation. Likewise, acupuncture and injection procedures have no proven efficacy (Bigos et al. When the patient is in a prone position, the paraspinal muscles relax, and any deformity caused by spasm subsides. The nurse asks the patient to bend forward and then laterally and notes any discomfort or limitations in movement. The nurse evaluates nerve involvement by assessing deep tendon reflexes, sensations (eg, paresthesia), and muscle strength. Nursing Diagnoses Most patients need to alter their activity patterns to avoid aggravating the pain. Twisting, bending, lifting, and reaching, all of which stress the back, are avoided. Bed rest is recommended for 1 to 2 days, with a maximum of 4 days only if pain is severe. If there is no improvement within 1 month, additional assessments for physiologic abnormalities are performed. Descriptions of how the pain occurred-with a specific action (eg, opening a garage door) or with an activity in which weak muscles were overused (eg, weekend gardening)-and how the patient has dealt with the pain often suggest areas for intervention and patient teaching. If back pain is a recurrent problem, information about previous successful pain control methods helps in planning current management. Information about work and recreational activities helps to identify areas for back health education. Because stress and anxiety can evoke muscle spasms and pain, the nurse needs insight into environmental variables, work situations, and family relationships. In addition, the nurse assesses the effect of chronic pain on the emotional well-being of the patient. Referral to a psychiatric nurse clinician for assessment and management of stressors contributing to the low back pain and related depression may be appropriate. The patient may sit and stand in an unusual position, leaning away from the most painful side, and may ask for assistance when undressing for the physical examination. Patients are taught to control and modify the perceived pain through behavioral therapies that reduce muscular and psychological tension. Diaphragmatic breathing and relaxation help reduce muscle tension contributing to low back pain. Guided imagery, in which the relaxed patient learns to focus on a pleasant event, may be used along with other pain-relief strategies (see Chart 68-2). As the back pain subsides, self-care activities are resumed with minimal strain on the injured structures. Position changes should be made slowly and carried out with assistance as required. The patient may find that sitting in a chair with arm rests to support some of the body weight and a soft support at the small of the back provides comfort. The patient rests in bed on a firm, nonsagging mattress (a bed board may be used). Lumbar flexion is increased by elevating the head and thorax 30 degrees using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient assumes a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head. The nurse instructs the patient to get out of bed by rolling to one side and placing the legs down while pushing the torso up, keeping the back straight. As the patient achieves comfort, activities are gradually resumed, and an exercise program is initiated. Initially, low-stress aerobic exercises, such as short walks or swimming, are suggested. After 2 weeks, conditioning exercises for the abdominal and trunk muscles are started. The physical therapist designs an exercise program for the individual patient to reduce lordosis, increase flexibility, and reduce strain on the back. It may include hyperextension exercises to strengthen the paravertebral muscles, flexion exercises to increase back movement and strength, and isometric flexion exercises to strengthen trunk muscles. For most exercise programs, it is suggested that the person exercise twice a day, increasing the number of exercises gradually. Some patients may find it difficult to adhere to a program of prescribed exercises for a long period. These patients are encouraged to improve their posture, use good body mechanics on a regular basis, and engage in regular exercise activities (eg, walking, swimming) to maintain a healthy back. Activities should not cause excessive lumbar strain, twisting, or discomfort; for example, activities such as horseback riding and weight-lifting are avoided. Providing the patient with a list of suggestions helps in making these long-term changes (Chart 68-3). The patient who is required to stand for long periods should shift weight frequently and should rest one foot on a low stool, which decreases lumbar lordosis. The proper posture can be verified by looking in a mirror to see whether the chest is up and the abdomen is tucked in. Locking the knees when standing is avoided, as is bending forward for long periods. When the patient is sitting, the knees and hips should be flexed, and the knees should be level with the hips or higher to minimize lordosis. The patient should sleep on the side with knees and hips flexed, or supine with knees supported in a flexed position. Nurse practitioners managing industrial injuries in primary health care clinics need to design treatment protocols that are effective for the employee and contain costs for the employer.

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The nurse changes dressings based on patient blood pressure medication how long to take effect order 100 mg toprol xl otc, wound hypertension vs pulmonary hypertension 100mg toprol xl visa, and dressing assessments arteria mesenterica superior cheap toprol xl 100 mg overnight delivery, not on standardized routines heart attack get me going extended version purchase toprol xl 50 mg without a prescription. Traditional nursing care plans recommended changing dressings on a routine schedule heart attack youtube generic toprol xl 100mg visa, often three or four times each day prehypertension high blood pressure purchase toprol xl in india. Newer, commercially produced moisture-retentive dressings can perform the same functions as wet compresses but are more efficient at removing exudate because of their higher moisture-vapor transmission rate; some have reservoirs that can hold excessive exudate. There is also evidence that moist wound healing results in wound resurfacing 40% faster than with air exposure. A number of moisture-retentive dressings are already impregnated with saline solution, petrolatum, zinc-saline solution, hydrogel, or antimicrobial agents, thereby eliminating the need to coat the skin to avoid maceration. Depending on the product used and the type of dermatologic problem encountered, most moistureretentive dressings may remain in place from 12 to 24 hours; some can remain in place as long as a week. They have no inherent adhesive and require a secondary dressing to keep them in place. Hydrogels are appropriate for superficial wounds with high serous output, such as abrasions, skin graft sites, and draining venous ulcers. Hydrocolloids are composed of a water-impermeable, polyurethane outer covering separated from the wound by a hydrocolloid material. As it evaporates over the wound, water is absorbed into the dressing, which softens and discolors with the increased water content. As the dressing absorbs water, it produces a foul-smelling, yellowish covering over the wound. This is a normal chemical interaction between the dressing and wound exudate and should not be confused with purulent drainage from the wound. Unfortunately, most of the hydrocolloid dressings are opaque, limiting inspection of the wound without removal of the dressing. Available in sheets and in gels, hydrocolloids are a good choice for exudative wounds and for acute wounds. Unless the wound is infected or has a heavy discharge, it is common to leave chronic wounds covered for 48 to 72 hours and acute wounds for 24 hours. As the wound progresses through the phases of wound healing, the dressing protocol is altered to optimize wound healing. It is rare, especially in cases of chronic wounds, that the same dressing material is appropriate throughout the healing process. The rule assumes that the nurse and the patient or family have access to a wide variety of products and knowledge about their use. The nurse teaches the patient or family caregiver about wound care and ensures that the family has access to appropriate dressing choices. Practice with dressing material is required for the nurse to learn the performance parameters of the particular dressing. Refining the skills of applying appropriate dressings correctly and learning about new dressing products are essential nursing responsibilities. Dressing changes should not be delegated to assistive personnel; these techniques require the knowledge base and assessment skills of professional nurses. Wet Dressings Wet dressings (ie, wet compresses applied to the skin) were traditionally used for acute, weeping, inflammatory lesions. They have become almost obsolete in light of the many newer products available for wound care. Moisture is absorbed into the foam layer, decreasing maceration of surrounding tissue. A moist environment is maintained, and removal of the dressing does not damage the wound. They are especially helpful over bony prominences because they provide contoured cushioning. Calcium alginates are derived from seaweed and consist of tremendously absorbent calcium alginate fibers. They are hemostatic and bioabsorbable and can be used as sheets, mats, or ropes of absorbent material. The alginate dressing forms a moist pocket over the wound while the surrounding skin stays dry. Alginates work well when packed into a deep cavity, wound, or sinus tract with heavy drainage (Krastner et al, 2002). Occlusive Dressings Occlusive dressings may be commercially produced or made inexpensively from sterile or nonsterile gauze squares or wrap. Occlusive dressings cover topical medication that is applied to a dermatosis (ie, abnormal skin lesion). Plastic film is thin and readily adapts to all sizes, body shapes, and skin surfaces. Plastic surgical tape containing a corticosteroid in the adhesive layer can be cut to size and applied to individual lesions. Eschar and necrotic debris are softened, liquefied, and separated from the bed of the wound. Several commercially available products contain the same enzymes that the body produces naturally. Application of these products speeds the rate at which necrotic tissue is removed. The nurse should expect this reaction, and help the patient understand the reason for the odor. Advances in Wound Treatment Increasing understanding of how skin heals has led to several advances in therapy. Growth factors are cytokines or proteins that have potent mitogenic activity (Valencia et al. Low levels of cytokines circulate in the blood continuously, but activated platelets release increased amounts of preformed growth factors into a wound. This increase in cytokines in the wound stimulates cellular growth and granulation of skin. Regranex gel contains becaplermin, a platelet-derived growth factor, which is applied to the wound to stimulate healing. Apligraf is a skin construct (ie, bioengineered skin substitute) imbedded in a dressing that also contains cytokines and fibroblasts. When applied to wounds, these agents stimulate platelet activity and potentially decrease wound healing time (Paquette & Falanga, 2002). Some oral medications are being investigated for their benefits in healing chronic venous ulcers of the lower legs. Pentoxifylline (Trental) increases peripheral blood flow by decreasing the viscosity of blood. It has some fibrinolytic action and decreases leukocyte adhesion to the wall of the blood vessels. Enteric-coated aspirin has also been shown to be of value, although its exact mechanism is still not clear (Valencia et al. High concentrations of some medications can be applied directly to the affected site with little systemic absorption and therefore with few systemic side effects. However, some medications are readily absorbed through the skin and can produce systemic effects. Because topical preparations may induce allergic contact dermatitis (ie, inflammation of the skin) in sensitive patients, any untoward response should be reported immediately and the medication discontinued. Medicated lotions, creams, ointments, and powders are frequently used to treat skin lesions. In general, moisture-retentive dressings, with or without medication, are used in the acute stage; lotions and creams are reserved for the subacute stage; and ointments are used when inflammation has become chronic and the skin is dry with scaling or lichenification (ie, leathery thickening). With all types of topical medication, the patient is taught to apply the medication gently but thoroughly and, when necessary, to cover the medication with a dressing to protect clothing. Suspensions consist of a powder in water, requiring shaking before application, and clear solutions, containing completely dissolved active ingredients. Lotions are usually applied directly to the skin, but a dressing soaked in the lotion can be placed on the affected area. A suspension such as calamine lotion provides a rapid cooling and drying effect as it evaporates, leaving a thin, medicinal layer of powder on the affected skin. Powders usually have a talc, zinc oxide, bentonite, or cornstarch base and are dusted on the skin with a shaker or with cotton sponges. Although their therapeutic action is brief, powders act as hygroscopic agents that absorb and retain moisture from the air and reduce friction between skin surfaces and clothing or bedding. The baths remove crusts, scales, and old medications and relieve the inflammation and itching that accompany acute dermatoses. The water temperature should be comfortable, and the bath should not exceed 20 to 30 minutes because of the tendency of baths and soaks to produce skin maceration. Spray and aerosol preparations may be used on any widespread dermatologic condition. Corticosteroids are widely used in treating dermatologic conditions to provide anti-inflammatory, antipruritic, and vasoconstrictive effects. The patient is taught to apply this medication according to strict guidelines, using it sparingly but rubbing it into the prescribed area thoroughly. Absorption of topical corticosteroid is enhanced when the skin is hydrated or the affected area is covered by an occlusive or moisture-retentive dressing. Inappropriate use of topical corticosteroids can result in local and systemic side effects, especially when the medication is absorbed through inflamed and excoriated skin, under occlusive dressings, or when used for long periods on sensitive areas. Local side effects may include skin atrophy and thinning, striae (ie, bandlike streaks), and telangiectasia. Thinning of the skin results from the ability of corticosteroids to inhibit skin collagen synthesis (Odom et al. The thinning process can be reversed by discontinuing the medication, but striae and telangiectasia are permanent. Caution is required when applying corticosteroids around the eyes because long-term use may cause glaucoma or cataracts, and the anti-inflammatory effect of corticosteroids may mask existing viral or fungal infections. Concentrated (fluorinated) corticosteroids are never applied on the face or intertriginous areas (ie, axilla and groin), because these areas have a thinner stratum corneum and absorb the medication much more quickly than areas such as the forearm or legs. Persistent use of concentrated topical corticosteroids in any location may produce acnelike dermatitis, known as steroid-induced acne, and hypertrichosis (ie, excessive hair growth). Because some topical corticosteroid preparations are available without prescription, patients should be cautioned about prolonged and inappropriate use. Intralesional therapy consists of injecting a sterile suspension of medication (usually a corticosteroid) into or just below a lesion. Although this treatment may have an antiinflammatory effect, local atrophy may result if the medication is injected into subcutaneous fat. Skin lesions treated with intralesional therapy include psoriasis, keloids, and cystic acne. Occasionally, immunotherapeutic and antifungal agents are administered as intralesional therapy. These include corticosteroids for short-term therapy for contact dermatitis or for long-term treatment of a chronic dermatosis, such as pemphigus vulgaris. Other frequently used systemic medications include antibiotics, antifungals, antihistamines, sedatives, tranquilizers, analgesics, and cytotoxic agents. Creams may be suspensions of oil in water or emulsions of water in oil, with additional ingredients to prevent bacterial and fungal growth. Oil-in-water creams are easily applied and usually are the most cosmetically acceptable to the patient. Water-inoil emulsions are greasier and are preferred for drying and flaking dermatoses. Gels are semisolid emulsions that become liquid when applied to the skin or scalp. They are cosmetically acceptable to the patient because they are not visible after application, and they are greaseless and nonstaining. The newer water-based gels appear to penetrate the skin more effectively and cause less stinging on application. They are especially useful for acute dermatitis in which there is weeping exudate (eg, poison ivy). Pastes are mixtures of powders and ointments and are used in inflammatory blistering conditions. They adhere to the skin and may be difficult to remove without using an oil (eg, olive oil, mineral oil). They are the preferred vehicle for delivering medication to chronic or localized dry skin conditions, such as eczema or psoriasis. Nursing Management Management begins with a health history, direct observation, and a complete physical examination. Because of its visibility, a skin condition is usually difficult to ignore or conceal from others and may therefore cause the patient some emotional distress. The major goals for the patient may include maintenance of skin integrity, relief of discomfort, promotion of restful sleep, self-acceptance, knowledge about skin care, and avoidance of complications. Axillary dressings can be made of cotton cloth, or a commercially prepared dressing may be used and taped in place or held by dress shields. A face mask, made from gauze with holes cut out for the eyes, nose, and mouth, may be held in place with gauze ties looped through holes cut in the four corners of the mask. Itch receptors are unmyelinated, penicillate (ie, brushlike) nerve endings that are found exclusively in the skin, mucous membranes, and cornea. Although pruritus is usually caused by primary skin disease with resultant rash or lesions, it may occur without a rash or lesion.

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Drusen (ie blood pressure chart 13 year old purchase toprol xl now, small hypertension jnc 7 ppt 25mg toprol xl amex, hyaline arteria coronaria derecha buy generic toprol xl 50mg, globular growths) blood pressure 40 over 20 order generic toprol xl on-line, commonly found in macular degeneration blood pressure chart uk nhs order cheap toprol xl on-line, appear to be yellowish areas with indistinct edges blood pressure kid buy toprol xl 100mg fast delivery. The External Eye Examination After the visual acuity has been recorded, an external eye examination is performed. The patient is examined for ptosis (ie, drooping eyelid) and for lid retraction (ie, too much of the eye exposed). The pupillary response should be checked with a penlight to be certain that the pupils are equally reactive and regular. An irregular pupil may result from trauma, previous surgery, or a disease process. The patient is asked to stare at a target; each eye is covered and uncovered quickly while the examiner looks for any shift in gaze. This is especially important when screening patients for ocular trauma or for neurologic disorders. This instrument enables the examiner to see larger areas of the retina, although in an unmagnified state. This instrument enables the user to examine the eye with magnification of 10 to 40 times the real image. The illumination can be varied from a broad to a narrow beam of light for different parts of the eye. For example, by varying the width and intensity of the light, the anterior chamber can be examined for signs of inflammation. When a hand-held contact lens, such as a three-mirror lens, is used with the slit lamp, the angle of the anterior chamber may be examined, as may the ocular fundus. For example, the inability to differentiate between red and green can compromise traffic safety. Some careers (eg, commercial art, color photography, airline pilot, electrician) may be closed to people with significant color deficiencies. The photoreceptor cells responsible for color vision are the cones, and the greatest area of color sensitivity is in the macula, the area of densest cone concentration. For example, red/green color deficiencies are inherited in an X-linked manner, affecting approximately 8% of men and 0. Acquired color vision losses may be caused by medications (eg, digitalis toxicity) or pathology such as cataracts. A simple test, such as asking a patient if the red top on a bottle of eye drops appears redder to one eye than the other, can be an effective tool. Changes in the appreciation of the gradations of the color red can indicate macular or optic nerve disease. Because alteration in color vision is sometimes indicative of conditions of the optic nerve, color vision testing is often performed in a neuro-ophthalmologic workup. The most common color vision test is performed using Ishihara polychromatic plates. On each plate of this booklet are dots of primary colors that are integrated into a background of secondary colors. Patients with diminished color vision may be unable to identify the hidden shapes. Patients with central vision conditions (eg, macular degeneration) have more difficulty identifying colors than those with peripheral vision conditions (eg, glaucoma) because central vision identifies color. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital area vein. Within 10 to 15 seconds, this dye can be seen coursing through the retinal vessels. Over a 10-minute period, serial black-and-white photographs are taken of the retinal vasculature. The dye may impart a gold tone to the skin of some patients, and urine may turn deep yellow or orange. The three most common types of tonometers are indentation, applanation, and noncontact. The indirect lens views the mirror image of the opposite anterior chamber angle and can be used only with a slit lamp. It consists of a geometric grid of identical squares with a central fixation point. The patient is instructed to stare at the central fixation spot on the grid and report any distortion in the squares of the grid itself. For patients with macular problems, some of the squares may look faded, or the lines may be wavy. Patients with age-related macular degeneration are commonly given these Amsler grids to take home. The patient is encouraged to check them frequently, as often as daily, to detect any early signs of distortion that may indicate the development of a neovascular choroidal membrane, an advanced stage of macular degeneration characterized by the growth of abnormal choroidal vessels. A visual field is the area or extent of physical space visible to an eye in a given position. Its average extent is 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees outward when the eye is in the primary gaze (ie, looking directly forward). It is a threedimensional contour representing areas of relative retinal sensitivity. Visual acuity is sharpest at the very top of the field and declines progressively toward the periphery. It is most helpful in detecting central scotomas (ie, blind areas in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa. Manual perimetry involves the use of moving (kinetic) or stationary (static) stimuli or targets. High-frequency sound waves emitted from a special transmitter are bounced back from the lesion and collected by a receiver that amplifies and displays the sound waves on a special screen. Ultrasonography can be used to identify orbital tumors, retinal detachment, and changes in tissue composition. Chapter 58 Assessment and Management of Patients With Eye and Vision Disorders 1753 centric circles dissected by straight lines emanating from the center. Automated perimetry uses stationary targets, which are harder to detect than moving targets. In this test, a computer projects light randomly in different areas of a hollow dome while the patient looks through a telescopic opening and depresses a button whenever he or she detects the light stimulus. Eyeglasses with a cylinder correction or rigid or soft toric contact lenses are appropriate for these patients. This definition does not equate with functional ability, nor does it classify the degrees of visual impairment. Legal blindness ranges from an inability to perceive light to having some vision remaining. An individual who meets the criteria for legal blindness may obtain government financial assistance. There are more than 1,046,000 legally blind Americans who are 40 years of age or older. African Americans have a higher rate of blindness than do Caucasians (Preshel & Prevent Blindness America, 2002). Individuals with visual acuity of 20/80 to 20/100 with a visual field restriction of 60 degrees to greater than 20 degrees can read at a nearly normal level with optical aids. Their visual orientation is near normal but requires increased scanning of the environment (ie, systematic use of head and eye movements). In a visual acuity range of 20/200 to 20/400 with a 20-degree to greater than 10-degree visual field restriction, the individual can read slowly with optical aids. Blurred vision from refractive error can be corrected with eyeglasses or contact lenses. Patients for whom the visual image focuses precisely on the macula and who do not need eyeglasses or contact lenses are said to have emmetropia (normal vision). They have deeper eyeballs; the distant visual image focuses in front of, or short of, the retina. When people have a shorter depth to their eyes, the visual image focuses beyond the retina; the eyes are shallower and are called hyperopic. These patients experience near vision blurriness, whereas their distance vision is excellent. Another important cause of refractive error is astigmatism, an irregularity in the curve of the cornea. Adapted from the International Classification of Diseases, World Health Organization, 1977; and from Vaughn, D. Individuals with hand motion vision or no vision may benefit from the use of mobility devices (eg, cane, guide dog) and should be encouraged to learn Braille and to use computer aids. The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts, (Preshel & Prevent Blindness America, 2002). Macular degeneration is more prevalent among Caucasians, whereas glaucoma is more prevalent among African Americans. The initial test may take the form of simply turning on the lights while testing the distance acuity. If the patient can read better with the lights on, the patient can benefit from magnification. Devices that test glare, such as the Brightness Acuity Tester, produce three degrees of bright light to create a dazzle effect while the patient is viewing a target, such as Snellen letters on the wall. Low-Vision Assessment the assessment of low vision includes a thorough history and the examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction. Specially designed, low-vision visual acuity charts are used to evaluate patients. Central acuity problems cause difficulty in performing activities that require finer vision, such as reading. Medical Management Managing low vision involves magnification and image enhancement through the use of low-vision aids and strategies and through referrals to social services and community agencies serving the visually impaired. The goals are to enhance visual function and assist patients with low vision to perform customary activities. The optical devices include convex lens aids, such as magnifiers and spectacles; telescopic devices; anti-reflective lenses that diminish glare; and electronic reading systems, such as closed-circuit television and computers with large print. Continuing advances in computer software provide very useful products for patients with low vision. Scanners teamed with the appropriate software enable the user to scan printed data into the computer and have it read by computer voice or to increase the magnification for reading. Provide support to families with newly diagnosed geneticrelated sensorineural disorders. Inquire about family members with other disorders that may include visual impairment, such as cutaneous, metabolic, connective tissue disorders, and hearing loss. Strategies that enhance the performance of visual tasks include modification of body movements and illumination and training for independent living skills. Head movements and po- sitions can be modified to place images in functional areas of the visual field. Community agencies, such as the Lighthouse National Center for Vision and Aging, offer services to low-vision patients that include training in independent living skills and the provision of occupational and recreational activities and a wide variety of assistive devices for vision enhancement and orientation and mobility. The acquired image is wirelessly transmitted to the chip, which provides a type of artificial vision and which, with training, allows the patient to achieve some useful vision. Although the device is still experimental, some work has been done with patients who have lost vision from retinitis pigmentosa and age-related macular degeneration (Humayan et al. The blind person relies on egocentric, sequential, and positional information, which centers on the person and his or her relationship to the objects in the environment. For example, the topographic concepts of front, back, left, right, above, and below and measures of distances are most useful in determining the exact position, sequence, and location of objects in relation to the person who is blind. Although their basis of information may be different from that of sighted people, people who are blind can comprehend spatial concepts. The goal of orientation and mobility training is to foster independence in the environment. Training may be accomplished by using auditory and tactile cues and by providing anticipatory information. Having a concept of the spatial composition of the environment (ie, cognitive map) enhances independence of those who are blind. Orientation and mobility training programs are offered by community agencies serving the blind or visually impaired. Training includes using mobility devices for travel, the long cane, electronic travel aids, dog guides, and orientation aids. The basic orientation and mobility techniques used by a sighted person to assist a person who is blind or visually impaired to ambulate safely and efficiently are called sighted-guide techniques. A blind or severely visually impaired patient requires strategies for adapting to the environment. The monocular postoperative patient whose functioning eye is restricted by a surgical patch or by postoperative inflammation requires early ambulation just like any postoperative patient. The activities of daily living, such as walking to a chair from a bed, require spatial concepts. The patient needs to know where he or she is in relation to the rest of the room, to understand the changes that may occur, and how to approach the desired location safely. This requires a collaborative effort between the patient and the nurse, who serves as the sighted guide. Patients whose visual impairment results from a chronic progressive eye disorder, such as glaucoma, have better cognitive mapping skills than the suddenly blinded patient.

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Contribution: this study provides an important contribution to the literature on system-level interventions to improve physician/scientist wellbeing hypertension hyperlipidemia discount toprol xl 100 mg, as it is one of the first to demonstrate the suspected link between supervisor characteristics and job satisfaction 5 htp arrhythmia generic toprol xl 50mg online. Higher quality leadership was associated with decreased burnout and increased job satisfaction among physicians being supervised blood pressure empty chart toprol xl 100 mg on line. Impetus: Burnout is prevalent in primary care physicians and is often associated with the work environment blood pressure chart diastolic low toprol xl 100mg without a prescription. However blood pressure 210110 purchase genuine toprol xl on-line, there are few studies which have examined the impact of workplace interventions on physician wellbeing and those that have are limited to single centers pulse pressure ejection fraction toprol xl 25 mg generic. Description: this cluster randomized trial evaluated 166 primary care physicians who were recruited from 34 Midwest and New York City practices and represented a mix of urban, rural, and suburban environments at academic and non-academic centers. Significantly more physicians who participated in the intervention had improved burnout and satisfaction. Data was presented in aggregate and did not specify whether there were differences in outcomes comparing environments (e. Contribution: this study demonstrates that innovation and attention to improved work conditions can have an impact on physician wellbeing. The major limitations of this study include the heterogeneity of the sampled practices and variation in intervention implementation. Impetus: the 2011 duty hours reforms were implemented with an aim of decreasing medical errors due to work-related fatigue. Although fatigue from excessive workload is thought to contribute to burnout, especially to emotional exhaustion, the extent to which duty hours restrictions affect burnout in residents was unclear. Description: In the study, first year residents at three large academic internal medicine programs (Mount Sinai, University of Pennsylvania, and Massachusetts General Hospital) were surveyed in 2008-2009 and in 2011-12 using the Maslach Burnout Inventory and Epworth Sleepiness Scale, allowing comparison of intern cohorts before and after implementation of 2011 duty hours reforms. Burnout was defined as meeting high sub-score threshold for either emotional exhaustion or depersonalization. For each intern cohort, burnout was measured in June prior to the start of the academic year and between April and June at the end of the intern year. The completion rate for the initial and follow-up survey was 62% (N=111) in the 20082009 cohort and 68% in the 2011-12 cohort (N=128). There was no significant difference for the 3-site cohort between 2008-2009 and 2011-2012 in end-of-year burnout prevalence (84% vs. Residents who reported caring for >8 patients on a service had higher incident burnout in 2011-2012 as compared to 2008-2009. No significant difference in end of the year excessive sleepiness scores was found. Although the design could be vulnerable to confounding due to use of a historical control cohort, rather than a randomized design, this study provides useful data to suggest that duty hours restrictions do not improve burnout or excessive sleepiness, confirms ongoing high prevalence of burnout in interns, and suggests that increased work compression under duty hours restrictions may be associated with incident burnout. Patient safety, resident wellbeing and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. Within 2-month long rotation blocks, residents were randomly assigned to overnight schedules of 24, 16, or 12 hours. Assessed outcomes were fatigue (Stanford Sleepiness Scale), burnout (Maslach Burnout Inventory) and somatic symptoms. Data from 47 residents (96% of sample), 971 admissions, 5894 patient-days and 452 staff surveys were analyzed. Patient outcomes including adverse events, mortality and continuity of care were similar across the three schedules. However, this study was underpowered suggesting that significant effects might have been missed. Contribution: the authors conclude that the findings do not support the alleged advantages of shorter duty schedules. However, a key finding is that is not adequately emphasized is that short duty schedules did not compromise patient safety and continuity of care while at the same time were associated with less physical symptoms in residents. Intervention to promote physician wellbeing, job satisfaction, and professionalism: a randomized clinical trial. Impetus: Physician burnout is a well-recognized problem, but most intervention studies focused on individual-level strategies such as mindfulness, which put the onus on the physician to make time to engage in a self-care activity. The goal of this study was to evaluate the impact of participation in facilitated support group sessions, for which the time was protected by the employer. The intervention group showed significant improvement in empowerment and engagement at work. The proportion of participants strongly agreeing that their work was meaningful also increased whereas the proportion decreased in the control and non-study cohorts, a finding that was statistically significant. These changes were evident by three months after the study and persisted at 12 months. There were no statistically significant changes in stress, symptoms of depression, quality of life or job satisfaction among the intervention group, control group and non-participants. Additionally, it showed that participation in a structured small group intervention format had a meaningful impact on several physician wellbeing measures. Effects of 2- vs 4-week attending physician inpatient rotations on unplanned patient revisits, evaluations by trainees, and attending physician burnout: a randomized trial. Impetus: Limited data exist on the effect of duration of internal medicine attending physician ward rotations as it relates to a variety of measures, including patient outcomes, learner ratings of attending physicians, and physician wellness. Description: this cluster, randomized, non-inferiority study examined the impact of varying service rotation length (two vs. The study randomized attending physicians to a 2- or 4-week rotation on an internal medicine inpatient service at a single, public teaching hospital for one year. The attending randomized to a 2-week rotation had lower burnout scores, as measured by the Emotional Exhaustion domain of the Maslach Burnout Inventory and other scales. Contribution: Though this was a single-center study limited to an academic medical center, it is an important addition to the literature examining the impact of work-intensity on attending physician wellbeing beyond looking strictly at work hours. It generates a number of suggestions for future study, including the conduct of a similar intervention in trainees and consideration for optimal rotation length in relation to wellbeing, teaching and learning. Cost: Support for this study was provided by a philanthropic gift from the Foglia Family Foundation. Continuity of care in intensive care units: a cluster randomized trial of intensivist staffing. This study assessed two alternate intensivist staffing schedules to determine whether outcomes for patients and intensivists differed between these staffing schedules. This study evaluated the impact of weekend respite for intensivists, with consequent reduction in continuity of care, on them and their patients. Daily coverage by a single intensivist in half-month rotations (continuous schedule) was compared with weekday coverage by a single intensivist, with weekend cross-coverage by colleagues (interrupted schedule). Intensivists experienced significantly higher burnout, work home life imbalance, and job distress working under the continuous schedule. Contribution: this study suggests that work schedules where intensivists receive weekend breaks improved the wellbeing of physicians without worsening patient outcomes. The authors suggest that this information can assist and inform intensivists, hospital administrators, and policy makers in choosing a model for intensivist staffing. Impetus: Physicians are put under increasing pressure to effectively and efficiently treat patients, resulting in increased burnout, stress, and job dissatisfaction. Physician burnout is associated with increased medical errors and patient dissatisfaction. Due to this correlation between physician wellbeing and performance, practice-level interventions designed to improve physician and organizational wellbeing are critical. Description: the goal of this intervention was to improve individual physician wellbeing in single, small primary care practice from 2000-2005. The 3-pronged intervention included (1) practice leadership attention to the value of physician wellbeing, (2) identification of factors impacting wellbeing. However, emotional and workrelated exhaustion of individual physicians and measures of organizational-health both significantly improved over the course of the intervention. However, this study provides a helpful framework for simple workplace interventions that can have an impact on physician wellbeing, particularly those that focus on control and meaning and leadership attention to physician wellbeing. Developing emotional intelligence in the clinical learning environment: A case study in cultural transformation. Impetus: Although cultural transformation is thought to be an important element of wellbeing programs, the effect of implementing programs targeting culture change on resident wellbeing is unknown. This paper aimed to understand the impact of curricular changes to transform the educational environment and promote a culture of resident wellbeing through a mixed-methods approach. Description: this paper describes a pilot study of a curriculum implemented in the Lehigh Valley Health Network Family Medicine Residency Program anchored on the concept of an emotionally intelligent learning community. That framework aimed to cultivate wellness through provision of time and space for self-care/reflection; safety through promoting vulnerability, asking for help, and admitting mistakes without fear of retribution; and development of interpersonal skills. Investigators used a mixed-methods evaluation strategy to examine data from 34 residents who were enrolled in the pilot program from 2007-2012. The measurements included the Fordyce Emotions Scale, Satisfaction with Life Scale, the Arizona Integrative Outcomes Scale, analysis of transcripts of "closing ritual statements" from resident assessment meetings, and analysis of transcripts from resident focus groups. Although quantitative measures of wellbeing did not change, themes from the qualitative analysis highlighted the positive culture and experiences with emotional awareness, self-care and reflection. The authors suggest that their results reflect that the intervention did not change the nature of the work, but rather normalized challenges of professional identity development. The authors hypothesize that existing psychometric tools may not be sensitive enough to capture valuable contributions from such interventions. Contribution: this study suggests potential usefulness of programs that normalize difficulties of professional identity development, and raises the important question of whether or not these programs should be mandatory. Although this study did not have a randomized design and may not be generalizable as a single-site study of a small number of residents, this study illustrates the value of rigorous qualitative evaluation to understand the impact of wellbeing interventions. The survey measures used in this study are not commonly used in current wellbeing research, and because burnout was not measured, we do not have an understanding of whether this program had an impact on burnout. The relationship between professional burnout and quality and safety in health-care: a meta-analysis. Impetus: Provider burnout has been associated with increased medical and surgical errors and decreased patient satisfaction, however the consistency and magnitude of the relationship between burnout and healthcare quality and safety has not been systematically, studied across disciplines. Description: this publication is a meta-analysis of 82 published and unpublished, predominantly crosssectional studies involving 210,669 health-care providers from 33 countries and multiple disciplines, across inpatient and outpatient settings. Studies were included if empirical data was used to quantify the relationship between burnout, quality and safety. Statistically significant negative relationships between burnout, care quality and safety were identified, with small to medium effect sizes. Greater provider burnout was associated with lower perceived care quality, reduced patient satisfaction, reduced quality indicators and reduced perceptions of safety. Potential moderators of the burnout-quality relationship were explored, including dimension of burnout, quality data source and unit of analysis (from individual provider to hospital/organization). Effect sizes were significantly stronger for individuals compared to larger service units, for emotional exhaustion compared to other dimensions of burnout, and whether providers were the quality data source. Potential moderators of the burnout-safety relationship were also explored, including safety indicator type, discipline (physician, nurse or interdisciplinary sample) and country. Effect sizes were stronger for nurses compared to doctors, and when providers were the safety data source. The potential impact of study rigor, outliers and publication bias was also assessed. Contribution: this is the first study to systematically and quantitatively analyze the relationship between health-care provider burnout and health-care quality and safety across disciplines and countries. Provider burnout accounted for approximately 7% of the variance in perceived quality and 5% of the variance in perceived safety of care. These relationships were robust to potential publication bias and ratings of study rigor, and highlight the consequences of burnout on the healthcare system at large. Changing the conversation from burnout to wellness: Physician wellbeing in residency training programs. Impetus: When this paper was written, few interventions to support wellbeing in residency had been described in the literature. This paper seeks to define a holistic definition of wellness and provide a toolbox to create a culture of wellness in residency. Description: this paper is a retrospective description of the development of a wellness program to promote "cultural change" in the Troy Family Medicine Residency, a community-based, university-affiliated family medicine residency program with 22 residents. They outline a "Wellness Toolbox" that includes ingredients for changing residency culture to be in support of wellness, as opposed to simply "preventing burnout. Importantly, they prioritize the need for a residency to agree on a shared definition of wellness and its components that is more than just the absence of burnout. The authors do not provide formal qualitative or quantitative outcome data on the effectiveness of the interventions. It may be especially useful as a starting point for programs that are beginning to develop wellness interventions. Though a useful framework, some of the specific strategies that are recommended may not be generalizable or feasible for large programs. Impetus: Successful resident learning is a combination of individual processes and collaborative and social processes. To maximize learning by residents, it is critical to understand not only the behaviors residents need to learn, practice and display, but also the characteristics of the clinical environment that promote resident involvement with clinical teams. Description: this study explored intern engagement in their clinical training programs at a New Zealand hospital through interviews and focus groups. Interview questions were designed to seek information about perceived useful clinical experiences, levels of team involvement and interaction, and situations or behaviors that facilitated or inhibited learning. Researchers synthesized data from interviews to create emerging themes and propose a tentative model that informed focus group discussions. Additional data was collected, analyzed, and combined with initial data to develop a second model. This revised model was presented to two groups of teaching practitioners for reactions, comments, and proposed revisions. Data was used to create a final model, which supported themes generated throughout the study. Contribution: A model of resident participation and learning was developed, which identified components necessary for the creation of positive learning environments.

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