Primary Medical Care Subject

COMMON LABORATORY TESTS AND INTERPRETATION 7. Covid-19 (corona virus disease 2019) Purpose: to determine a current infection, antibody may reveal previous infection Specimen: nasal swab or venous blood Normal values: negative Pic available from https://www.shutterstock.com/th/image-photo/covid19-nasal-swab- laboratory-test-hospital-1670462338

topic Summary To conclude…  Laboratory and diagnostic tests performed are essential for patients in order for them to receive appropriate treatment or care .  In primary medical care context, the initial laboratory tests are included: FBS, UA, CBC, Sputum Ex., Stool Ex. and also the current epidemic diseases such as Flu test, and Covid-19 test.  Interpretation of laboratory test results compared with normal range or grading style which can enable patients to understand more regarding their current condition.

Thank You! Wanpen Waelveerakup, Email: [email protected] Ruffel Joy C. Manalo, Email: [email protected]

Unit VI Rational Drug Use Wanpen Waelveerakup, RN, Dr.PH Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing Nakhon Pathom Rajabhat University Thailand

Learning Objectives OF THE TOPIC After studying this topic, the students will be able to …. Describe the definition of rational drug use. Describe the framework of rational drug use. Identify the good prescribing practice for rational drug use in primary medical care context.

1. Definition of RDU 3. Good prescribing practice for RDU 2. The framework of RDU

1. The definition of rational drug use (RDU): Rational drug use or Rational use of medicines “Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.” (WHO, 1985 available from https://www.who.int/medicines/areas/rational_use/en/)

2. The framework of RDU •The framework of RDU: indication, efficacy, risk, cost, other considerations, dose, method of administration , dosing frequency, duration of treatment, and patient compliance. 2.1 Indication Take medication when needed (more beneficial than penalty)

2. The framework of RDU 2.2 Efficacy The drug is really useful to people. There is sufficient supporting evidence. The benefits differ from placebo and have a clinical significance. 2.3 Risk Consider the main safety of the patients 2.4 Cost Use sufficient and worthwhile medication

2. The framework of RDU 2.5 Other considerations Knowledgeable, careful, responsible and use drugs in accordance with the academic standards. 2.6 Dose Use the right dose, not too small nor too much, don’t adjust the medication by yourself. 2.7 Method of administration Take the medicine correctly.

2. The framework of RDU 2.8 Dosing frequency Take the medicine at the right frequency 2.9 Duration of treatment Take medication during the appropriate treatment period. Not too short nor long period 2.10 Patient compliance Taking of medication with regards to patient’s convenience and acceptance

3. Good prescribing practice for RDU: 3.1 Antihistamine Antihistamines can be divided into 2 groups: 3.1.1 non-sedating antihistamine (Low-dose antihistamines), also known as the second (or newer) generation antihistamine (Second- generation anti-histamine drugs) • Examples of drugs in this group are cetirizine (a) loratadine (a) desloratadine (am) fexofenadine (am) and levocetirizine (am) etc. • Examples of trade names of drugs in this group are Zyrtec®, Clarityne®, Aerius®, Telfast®, and Xyxal®, etc.

Good prescribing practice for RDU: 3.1 Antihistamine 3.1.2 Sedating antihistamine (Sleepy antihistamine drugs), also known as the first generation antihistamine • Example of drugs in this group are: - Brompheniramine maleate (ก) - Chlorpheniramine maleate * (ก) - Diphenhydramine hydrochloride (ก) - Dimenhydrinate (ก) - Triprolidine (น) and Aebhydrolin (น) etc. Note * Currently, the new name is called Chlorphenamine

Good prescribing practice for RDU: 3.1 Antihistamine • The first-generation anti-histamine drugs may be used to alleviate a runny nose for colds to some patients in some cases. But not for children under 6 years of age, especially infants younger than 1 year because it can be very dangerous. • Be careful when using first-generation anti-histamine drugs with - while driving vehicles or work at risk for an enlarged prostate. - Epilepsy, - Glaucoma, - HT or cardiovascular disease. - Bronchitis and, asthma, - Impaired liver or kidney function.

Good prescribing practice for RDU: 3.1 Antihistamine • Both antihistamines are registered use in allergic diseases such as allergic rhinitis, urticaria and etc. •The conclusion is not to use non-sedating antihistamine in order to relief colds since there is no effectiveness in both children and adults. •The general use of drug is unreasonable.

Good prescribing practice for RDU: 3.2 Domperidone (ก)1 • Indication of dosage and duration of medication to reduce the risk of heart failure as follows: 1) Used to relieve nausea and vomiting in a short period of no more than 7 days. 2) Cancel other indications of medication such as relief of dyspepsia and GERD 3) Use in adults no more than 10 milligrams per time (1 tablet) no more than 3 times a day (Max. 1x3 oral ac) - Use In children, a dose of 0.25 mg / kg at a time not more than 3 times a day should be taken on an empty stomach.

Good prescribing practice for RDU: 3.2 Domperidone (ก)2 5) Do not use domperidone with people who have blood abnormalities in mineral potassium or prolonged QT, low magnesium in the blood, high potassium in the blood since there is a higher risk of prolonging QTc. 6) Do not use domperidone to people with heart disease such as existing heart failure or bradycardia. 7) Do not use domperidone with moderate to severe impaired liver function. 8) Domperidone should not be used regularly to stimulate breast milk. When in use, it should not exceed the size specified above, should only be used for the shortest duration and should not be used during the first week after birth.

Good prescribing practice for RDU: 3.3 Paracetamol (ก) Used mainly with regard to effectiveness and safety for the liver. -Take the dose at 10-15 mg / kg / time in both children and adults, calculated according to the ideal body weight. In the case of child or adult obesity, take paracetamol tablets (500 mg) - People who are underweight (such as 50 kilograms) should not receive 2 pills at a time because they will have an overdose. • The right dosage is 1 tablet or 1 and a half tablets - People who are overweight (such as 67 kilograms) should not receive 1 tablet at a time because they will have an underdose. - • Suitable dosage is 2 tablets at a time-

Good prescribing practice for RDU: 3.3 Paracetamol (ก) In the case of child or adult obesity take paracetamol tablets (500 mg) • No more than 4,000 milligrams per day • Paracetamol should not be used more than 2,000 milligrams per day for long- term use in adults, such as osteoarthritis. • Avoid using paracetamol in combination with alcohol to prevent liver aggravation and may be toxic to the kidneys, even in small amounts. In the case of child or adult obesity take paracetamol tablets (325 mg) • No more than 3250 milligrams per day (no more than 10 tablets per day)

Topic Summary The rational use of medicine is an essential indicator that reflects the quality of health services. So that a medicine and practitioner should be used appropriately with regards to its proven benefits, the lesser risk and at its lowest cost for them and their community. The rational use of drugs require patients to receive medications appropriate to their clinical needs, in doses that meets their own individual requirements at an adequate period of time for the patient..

Thank You! Wanpen Waelveerakup, Email: [email protected] Ruffel Joy C. Manalo, Email: [email protected]

Dermatosis or Skin Diseases Wanpen Waelveerakup, RN, Dr.PH (Public Health Nursing) Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing, Nakhon Pathom Rajabhat University Thailand

Learning Objectives OF THE TOPIC After studying this topic, the students will be able to ….  Identify the signs and symptoms of dermatosis.  Determine the appropriate treatment and care for patients with signs and symptoms of dermatosis.

Scope of the topic •Definition of dermatosis •Dermatosis caused by bacterial, fungal, and viral infections •Dermatosis infections caused by allergies

What is the definition of dermatosis (skin disease)? Skin disease is an inflammatory disease involving the sebaceous glands of the skin; characterized by papules or pustules or comedones. Dermatosis, disorder involving lesions or eruptions of the skin. Cause: occurred in both the epidermis (epidermis) and dermis

Skin Layers Weber J. & Kelly H. J. (2010) Health assessment in nursing. 4th Edition. New York, USA: Lippincort Williams & Wikins.

• Hormonal disorders Blockage or inflammation of the pores, including acne. • The use of drugs, cosmetics, radiation and sunlight, such as freckles and Melasma. • Bacterial infections, including (abscess), cellulitis and impetigo •Skin diseases caused by viral infections, such as AIDS, herpes, chicken pox, rubella and warts.

• Eczema • Ringworm • Foot bite disease or Hong Kong feet • Dandruff or scalp fungus • Nail fungus

Skin diseases caused by allergies • Pollens • Fur • Food •Drugs Skin diseases caused by malnutrition including lack of vitamin B3.

caused by genes or disorders during pregnancy including moles, birthmarks. caused by skin disorders or caused by many reasons, such as corns psoriasis caused by metabolic diseases such as DM, hypothyroid (myxedema, thyroid gland works abnormally little.)

Dermatosis symptoms • The intensity depends on the type and the causes of the disease • Skin lesions include rash, cysts, pus-filled sacs, blisters, swelling, discolorations, bumps, hardening, or any other change in or on your skin •Some skin diseases occur in the dermis that causes bleeding. In which the skin is prone to stinging, itching and pain at the areas of redness, blisters, or sores.

Dermatosis infections caused by • Bacteria • Fungus • Virus

Dermatosis caused by bacterial infections 1. Abscess 2. Blister (Impetigo, Eczema) 3. Dermatitis (Cellulitis) 4. Erysipelas รายวิชาการรกั ษาโรคเบอื้ งตน้ (อ.ดร.วนั เพญ็ แวววีรคปุ ต)์

1. Abscess Pus Picture available from https://medthai.com/%E0%B8%9D%E0%B8%B5/

1. Abscess • Inflammation of the sebaceous glands and hairs commonly found in people of all ages. • People with diabetes or frequent steroid use may experience frequent occurrence of abscesses. • Most often have only one head, some people may have multiple heads in succession called Carbuncles. Cause - Caused by the bacterium Staphylococcus (Staphylococcus) or may be by direct contact with infected patients.

Abscess symptoms •A nodule or swelling, redness, pain, hair, or hair in the middle of the lesion. •If abscess located nearby lymph nodes may be swollen and painful. •In the case of carbuncle, fever, and fatigue may be accompanied. •In the case of a single abscess, a scar is a common symptom when healed.

Abscess treatment 1. Weaacrhmticmoem. press by applying 2-3 times a day for 10-15 minutes 2. Provide pain relievers to reduce fever 3. Give antibiotics 5-7 days such as : Cloxacillin 250-500 mg 1x4 per oral pc : Erythromycin 500 mg 1x4 per oral ac 4. Incision and drain if needed.

Suggestions 1. If the abscess is frequent, it may indicate low immunity, nutrient deficiency, anemia, diabetes, or long term use of steroids find out the cause and provide care of the underlying disease. 2. Should prevent the occurrence of the abscess by bathing or washing the body with a soap 2 times a day. 3. Do not squeeze the abscess, especially if it rises in the center of its face.

2. Blister (Impetigo, Eczema) Picture available from http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=203

Symptoms •Firstly, it will look like a red rash and itching, later, the blisters become clear, easily broken, becomes red with sticky, greasy lymph attached to it like a cigarette when the first rash broke. Often with a rash appearing in many nearby areas. •Low fever or enlarged lymph nodes •It usually occurs on the face, ears, nose, mouth, head, buttocks, and the extremities of the limbs (such as hands, legs, knees). •It may be a complication of other skin diseases such as scabies, chickenpox, herpes zoster/simplex, a rash, allergic rash, etc.

Complications and treatment •Com-plSiceaptsiiosns - Group A streptococcus may cause nephritis. •Treatment 1. Shower with soap 2 times a day and use potassium permanganate to wash away the flakes. 2. If itchiness is observed, give antihistamines such as - Chlorpheniramine: C.P.M. 1x3, 1x2, oral pc or 1xhs

Treatment 3. Apply the wound with tetracycline ointments or gentamicin cream or gentian violet after every shower. 4. Prescribe antibiotics such as : Cloxacillin 250-500 mg 1x4 per oral pc : Erythromycin 500 mg 1x4 per oral ac • If improved in 3-5 days, the drug should be continued for 10 days to prevent nephritis. (In cases it is caused by group A streptococcus), or if the condition does not improve especially in infants, they should be admitted to the hospital.

3. Cellulitis • General characteristics Subcutaneous tissue inflammation is an inflammation of the subcutaneous fat layer Cause -Streptococcus or Staphylococcus Symptoms - The skin is characterized by swelling, redness, warm, and pain. - The margin of lesion is not clear, often occurs along the limbs - Fever, Fatigue, Anorexia - Lymph nodes enlargement

Cellulitis Images available from Images available from http://cai.md.chula.ac.th/lesson/s https://ercare24.com/cellulitis-emergency/ kin/pic/page7.htm

Complications and treatment • Complications - Sepsis Treatment 1. Take a rest & immobilized the inflamed area, raise the inflamed arms or legs to a high level and use warm compression. 2. Give pain medication to reduce fever or pain and; 3. Give antibiotics such as : Cloxacillin 250-500 mg 1x4 per oral pc : Erythromycin 500 mg 1x4 per oral ac •If improved in 3-5 days, the drug should be continued for 10 days for prevention a recurrence, •If the condition does not improve in the patient should be admitted to the hospital. May need to inject 600,000 penicillin into the muscle 2 times a day.

4.Erysipelas - Inflammation of the dermis and subcutaneous tissue (superficial subcutaneous tissue inflammation) is caused by a bacteria called Beta Streptococcus A Group • Symptom - Acute fever, chills, headache, fatigue, loss of appetite, pain, swelling, redness in the skin at the beginning with a small point and continue to expand. - The skin around the area is clearly convex, separating the edges from the normal skin. When pressed, the color will fade with a slight indentation - If the size is large, there may be blisters. - Often occurs in the face, in one or both cheeks, arms or legs, if frequent, may cause the lymphatic tubes to swell permanently.

Erysipelas Images available from http://www.atlasdermatologico.com.br/disease.jsf? diseaseId=132

Complications and treatment • Complications - Sepsis Treatment 1. Take a rest & immobilized the inflamed area, raise the inflamed arms or legs to a high level and use warm compression. 2. Give pain medication to reduce fever or pain and; 3. Give antibiotics such as : Cloxacillin 250-500 mg 1x4 per oral pc : Erythromycin 500 mg 1x4 per oral ac •If improved in 3-5 days, the drug should be continued for 10 days to prevent recurrence, •If the condition does not improve, the patient should be admitted to the hospital. May need to inject 600,000 penicillin into the muscle 2 times a day.

Dermatosis caused by fungal infections Images from https://beezab.com/%E0%B9%82%E0%B8%A3%E0%B8%84%E0%B9%80%E0%B8%81%E0% B8%A5%E0%B8%B7%E0%B9%89%E0%B8%AD%E0%B8%99/ รายวิชาการรกั ษาโรคเบอื้ งตน้ (อ.ดร.วนั เพ็ญ แวววรี คปุ ต)์

1. Tinea, Ring worm •Eczema or dermatophyte dermatitis (dermatophyte) around the skin, hair, nails, hair follicles. •Most fungi grow in the epidermis. • The human skin contains antifungal agents and peeling off of the epidermis. •Common in warm and humid countries. •Risks: DM, immunocompromised individuals, take antibiotics, and hormone therapies for a long period of time, share items with people who were infected.