LA Vs GA, Closed Vs Open

The advantages of local anaesthetic are:
1. Quicker recovery time allowing for earlier discharge.
2. The local injection will act as pain relief over the hernia area for a period of time after the operation has finished
3. Less risks associated if you have any other concurrent illnesses eg:lungs or heart

The disadvantages of local:
1. The patient will be awake
2. The patiemt may flee pressure over that over during the operation
3. there is increased liklihood of local structure damage

Laparoscopic:
advantages are:
*less painful
*earlier discharge
*smaller incisional site

disadvantages are:
*more expensive
*risk of conversion to open
*always need a general anast
*unsuitable for some hernias

Open surgery
advantages are:
*can be done under local or general
*has been performed by more surgeons for a longer period of time
*suitable for alll types of hernias

disadvantages:
*longer hospital stay
*more painful post op

Making Errors

Digoxin Side Effect 
Excessive/ppt by hypokalaemia: anorexia, nausea, vomiting, diarrhoea, abdominal pain, visual disturbances, headache, fatigue, drowsiness, confusion, dizziness, delirium, hallucinations, depression, arrhythmias, heart block
Tx: Potassium-sparing diuretics, potassium supplements, digoxin-specific antibody fragments

Mx: blood levels, cardiac monitoring

Methotrexate 

Toxicity: anorexia, diarrhoea, toxic megacolon, hepatotoxicity, pulmonary oedema, dizziness, blood disorders (sore throat, bruising, mouth ulcers), liver toxicity (nausea, vomiting, abdominal discomfort, dark urine), respiratory effects (shortness of breath)

Mx: FBCs, LFTs, Obs

Insulin 
OD: hypoglycaemia

Tx: 50% dextrose, IM glucagon, sugary drink

Mx: Blood glucose

Warfarin 
OD: haemorrhage

Mx: INR, withhold warfarin, Vitamin K

Penicillin Allergy 
Anaphylactic Reaction: urticaria, angiooedemam, fever, inflammation

Mx: Stop antibiotic, adrenaline, chlorphenamine, steroids, fluid

Communications:
- Apologise 

- ?Admit responsibility- Explain carefully what has happened
- Short-term effects
- Long-term effects
- "This shouldn't have happened and we will do everything we can to make sure it does not happen again
- There are many checks and balances"- Notify senior
- Will make an inquiry/Fill in incident form
- Direct to PALS (Patient Advice and Liaison Services)

- Independent Complaints Advocacy Service (ICAS)
- Complaints can be made to Trust Complaints Manager 

- Can talk to consultant

- Write to ward manager
- Give name and bleep number

Alzheimer's Counselling

Alzheimer’s

Normal

-          lose memory, brain cells, difficult to retain information

Alzheimer’s

-          more pronounced

-          changes in brain structure (plaques, tangles, loss of mass) and reduced chemicals involved in transmission of signals

How?

-          familial (early position)

-          basically unknown

Does it get better?

-          progressive

-          starts with forgetfulness/wandering

-          problems with cooking, cleaning, dressing

-          speech

-          difficulty recognising people

Tx

-          no cure

-          just slow progression of disease, reduce anxiety and memory loss

-          Donepezil, rivastigmine, galantamine (Ach-esterase inhibitors)

Side Effects (resolve within few weeks)

-          sleep disturbance

-          nausea

-          loss of appetite

-          diarrhoea

-          muscle cramps

ECG before & regular review

Support

-          community nurses

-          home carer

-          social worker

-          occupational therapist

-          respite care

-          Day Hospital – group Tx

-          Alzheimer’s society

-          Dementia Relief Trust

Steroid Counselling

Hello_____
My name is ________
I'm a __________

Find The Problem
I understand that you've been recently been put on steroids. How do you feel about that? What do you know about steroids? You understand what it is for? Do you have any understanding of the side effects?

Information

Steroids are naturally produced in the body and help reduce inflammation and swelling. Steroids are often used synthetically to help with health problems characterised by inflammation. They are very different from the kind that you hear about in the news that athletes take - those are known as anabolic steroids and act differently on the body.

However, steroids aren't used unless they have to as they have these side effects, but these usually only occur after prolonged use and with higher doses, and we monitor carefully to see if any of these occur.

These include:
Infection - immunosuppression
Higher blood pressure - monitored regularly
DM - can happen go to GP if feeling tired/going to the toilet more
Osteoporosis - thinning of bones - supplements of Ca and Vit D/bisphosphonates/HRT
WG - fullness of face
Increase in appetite
Skin thinning - bruising
Mood change - irritable/depressed
Dyspepsia - indigestion/stomach upsets

General Advice
Blue steroid card - keep with and inform doctors so they can prescribe safely for you. You can also wear a bracelet to let paramedics know.

You musn't stop suddenly as while you take this medication the body produces less of its own steroids, adn stopping suddenly can cause your body to react badly - for example causing confusion, abdomoinal pain, and can require you to go to hospital.

Avoid smoking/drinking
Avoid ibuprofen
as they can increase the likelihood of indigestion

PMHx
Do you suffer from epilepsy/osteoporosis/diabetes/hypotension/excessive bleeding/tuberculous/chicken pox/stomach ulcers?

DHx
Do you take NSAIDs/any other medication?
Allergies?

SHx
Smoke/Drink

Is that all clear? How do you feel about that? We can arrange a follow-upappontment with GP if you have any further questions you want to ask. What have you taken away from this?

I can give you some leaflets. Steroid cards also carry a lot of info, so don't worry if you forget.