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Can you see it as it changed? Yeah, it's all good. Perfect. Okay. So thank you for that introduction. Yes. So my name is Millie or Amelia, whatever you want to call me. Um and I'm gonna go through drug and fluid prescribing. This is a bit of a dry topic. Um So I've tried to make it as interactive as possible. I'll have a couple of questions, um which you might want to be enough for. So if you have to be enough on your phone or a copy, grab that. Now, um please put any messages, all questions in the chat at any point if you want to know anything. So we're gonna start with some drug prescribing. We'll look at some terminology and then we're gonna run through what is a typical drugged out? And then we're gonna look at fluid prescribing as well and have a few examples. So first of all terminology, so this is where you want to have your get the chat open because I want you guys to all least have a think about what you think these things mean if it works okay, I'll just have to do that. Okay. So do they not know what this means but my thing is being spread. Yeah. Perfect. Yeah. So it's oral. So I think part oral and you can just do an O but typically people, right P O. What does this mean? Subcutaneous? Yep. Sub cut. Perfect. This one. Which cancer was it? IV. Get. No, no, no. This is a slight, slightly harder. Maybe. Yeah. Good. Top, cool, nice. This one inhaled good and this one sublingual good, nice. Okay. So next slide bit more terminology. This is about frequency of drugs now. So once a day. Yeah, perfect about this one. Perfect. You might see a bit of a theme occur. Now that one, three times a day nights, that one nice, four times a day is getting this okay right now. Can you tell me what this is? Yes, once morning not to be confused with. So it's not once a month. Sometimes people use it. I would use that as once morning. Um Can you guys see my mom? Can you see my mouse actually? Yeah, we can. Perfect. Yeah. So this is once morning, if you want something, once a month, I would write out the words once a month or monthly. Okay. Um And then this one, once a night. Perfect. Exactly. So good. You guys seem to know your terminology. So now we're going to look at a typical drug chart. So just a little caveat. This is um a drug chart that I work at the Princess of Wales Hospital in Cup in Bridgend, in Wales. So this is the drug chart that we use. Different hospitals will have slightly different drug charts. But generally speaking, they're all going to follow the same formula in that you have different sections for different types of medications. So you'll start with the allergy section imperative that you fill this out. So circle name, you have to sign it the date and you are signing your name to the person to say that this person either has an allergy or doesn't. So make sure it's right. Obviously put patient sticker, if you want a sticker, write it down. Ideally, you want height and weight for your patient because some medications need that. So it's important to get it few details about uh their admission and then other charts. So sometimes patient's will have a Warfarin chart which looks no, but like this, uh sometimes patient's might have an insulin chart. I think that's all the charts I've got. Yeah. So they might have other charts you need to tick what it is and then say whether this is the first chart, second chart or whatever our prescription, our charts have a little bit uh an area for oxygen as well. Um So obviously it's almost got COPD or something like that. We're going to be prescribing 88 to 92. You can also write this on their news chart. Okay. This is the acute medication sections. This is for your one off doses. Um, so things like an emergency situation that if you're, maybe you've got cardiac arrest, this is where you're going to be writing those doses is for one off emergency things that you don't want to be repeated. And then this is just a pharmacist bit. Basically, you don't have to worry about it. It's where they write things. Don't, don't go near it basically. Okay. So, acute medications. So this is on the front of the drug chart as I said, it's for um, yeah, it's for emergency or acute situations other they would suggest. So I've got a little bit of a case for you guys here. So it's not particularly hard. Uh, so 57 year old man, office worker, smoker high B M I presents with central crushing chest pain radiating to the left arm and he is sweating. So there's a few medications that they, that he might want to give him. But can you guys give me some good? Yeah, I've got any other suggestions of other acute meds that you might want to give this patient? Yeah. Good, good. Stunning. Okay, good. Those are the ones I thought of. Okay. So yeah, so we can give Aspirin, we can give more for him. We can do TN um and he might need some option as well, but obviously we're not going to be prescribing oxygen here. So I've gone for. So my click is not working. Okay. So I'm gonna give him some aspirin. A few people have already said in the chat, how much aspirin and how are we going to give it? No, no. So what's the dose? Yep. Perfect. So we're gonna give 300 mg and we're going to give it Worley and we want to give it stopped as well. So this is what it should look like when you write it in. So the date, you don't always have to put the year, just a little tip around Christmas time. And the new year I start writing the year in it just to make it really clear. The drug does the drug name not make it nice and clear. You don't have to do capitols. But if you're prone to be a little bit messy with your writing, do capitals. If it's better. 300 mg, make sure that m and that gr really clear, obviously, the root is oral time to be given stat, pretty much every one of these medications you're gonna be filling in. You're going to be writing stat because if it's, there's no reason for it to be on the acute side if you're going to say or give it in an hour, okay, and then sign it and put your bleep number if you have one. So, and that is basically anything, everything you need to know about acute medications, there's really not much to it. This bit is for the nurses or those giving the medication so you can just ignore that. Okay. So next section is antibiotics. So, on our drug chart and most drug charts you'll find. So you've got the front page open up. First page you're gonna come across is antibiotics. So this has got three pages which I've pictured here. So you've got page 12 and three. So this is the first page that you're going to write and medications on and this is the first section you're gonna write medications on. So, time to get your B N F up guys. So we've got a 75 year old female who comes in with worsening shortness of breath, productive cough for four days. Okay. So these are her observations or the relevant observation and these are the bloods, not, you know, relevant bloods. So what do you think this patient needs in terms of antibiotics? Oh, give you guys a little moment. Okay. We've got some suggestions. Contraction and azithromycin. Anything else? Thank you, Marisa here. Amoxicillin or locks on a lot of moxie feelings coming. Very nice. Someone said amoxicillin have no allergies. Very good. Uh levothyroxine. Uh Dent. Ok, good. Yeah, so a lot of suggestions. Very sensible suggestions. So first thing in this situation, hopefully, you guys, um you know, I haven't, I haven't given you tons of detail, but this is likely to be a pneumonia or a chest source of infection. She's got worse and short of breath and productive cough. Obviously, it could be something like heart failure as well. We don't know, uh, it could be COVID, but let's run on the assumption that this is a pneumonias. So we're gonna need to do the curb school. So this patient, there's nothing here that says anything about confusion. In fact, it says alert orientated to time place person. So that's not, hasn't scored for that. You and then the you is your ear. Nothing about high urea. You've got respirato, the respirator is over 30. So that's a curbs, that's one. Um Then we've got BP, BP is under 90 systolic, that's two and then uh 65 issue over 65. Yes, she is. So there's curb score of three. Yeah, good. So someone said check the micro guide for trust as well. So according to and this is what my trust guidelines say that we need to give amoxicillin IV, 1 g tds and Clarithromycin orally 5 500 mg BD. So Mark Sicilian is going to cover everything. Um pretty much everything. It's a very good board spectrum and then Clarithromycin is going to cover your more atypical things like each another. Um It does suggest for severe or curb score of over three, you can actually give amoxicillin or really still. Um But I'm going to say for this patient, I'm going to suggest that she's done well enough that we're gonna give her IV typically, um you can give a closer Mycin IV, but we tend to give it orally if it's possible because if it goes through IV, it can be quite irritant. Um, and particularly if a, if a cannula blows or, and it starts going into the, into the tissue, it can be really, really irritating, irritating. Okay. So this is what it's going to look like when we've written it up. So date route, I've ticked the time. So I'm giving it three times a day. I've gone from morning, midday at bedtime. If you want to do it evening, that's fine. This is just, typically, it's a little bit of, you know, I guess trial and error sometimes, sometimes you want to give it morning, midday evening, sometimes give it a bedtime. Doesn't matter. Just trust to go for what you feel like right up the name. So I've not gone for Capitols, but you can clearly see what I've written indication community acquired pneumonia and then ignore this bit here. This not every drug chart has this. Um So I'm not going to go into that. Just ignore that. I've used the guidelines. I've signed it if you don't have a nice short signature. Now is your time to develop one because you don't have a lot of time and space to write it. Of course, your bleed number, I've been put in the dates that they're gonna have it and the days. So how many days are having it for? And then same down here. So 500 Clarithromycin cap guidelines signed it okay. You'll notice down here in the special instructions. I put legionella with a little box. That's because we need to send off a legion. We need to send off a urine sample to test for the legionella. And when, when that comes back negative, we can stop the cholesterol rising because that's all that's really covering the amoxicillin is good enough by itself. Okay. So three days go by. So we're now on the 18th. Okay. Legionella comes back negative. Stunning. So I don't need the Clindamycin anymore. Cultures and sensitivity spewed of dispute and comes back as sensitive to amoxicillin. Good. So we are using the correct antibiotic and the, and the patient's responding really well to treatment. So that's all good. What do, what do we do guys? Any suggestions? Good. Sensible. Yep. Step down IV to oral recheck inflammatory markers. Yep. Good yet. Okay. Yeah. So very sensible suggestions essentially. Yeah, we want to, we need to re evaluate the situation, don't we? Because you know, we're, we're on the 18th were coming to the end of our drug chart here. We need to think about, are we going to keep going with IV, we can definitely stop the Clarithromycin as well. Um So what is it? So it will look like this? Ignore, ignore. So, sign, sign sign and we're here what we're going to do. So I've suggested we're gonna, so in this drug chart. We have this little great, this little brown box which says, so after 72 hours, we need to review it and decide what we're doing so we can stop it, which is what we're going to do with Chris Morrison. We can continue, we can do an IV door or switch, change the antimicrobial, we can continue the same one or we can change it completely, make sure you're signing and signing these ones as well. Okay. So, so let's say we've discussed with the senior when'd and microbiology have also got involved and they advised that you switched the patient to an oral amoxicillin for 10 days in total Clarithromycin can be stopped as we said. So if I show so this drug chart, we've used this page, we can either move onto this page which looks like this to the second page and you can see there's space for a few more days. So it should look like this. So we're not continuing the Clarithromycin and you, but you would be writing it here if you would continue the Clarithromycin, but we're just going to continue the amoxicillin. So the new date, which is now the 18th, we're going to give it all really now and we're changing, we need to change the uh so the dose is still the same, I believe. Um make sure that you're changing the day. So this is day four, you'll notice that I've crossed out the first dose and that is because they've already had the first dose on the 14th. Okay. So when you're rewriting drug charts, it's really important that you make sure that you're crossing out any doses they've already had. Because if it's maybe like 10 o'clock in the morning, the nurse might see this and say, oh, I need to give a, need to give them that dose, but they've already had it. Ok. So make sure you're crossing out that dose. But if you notice here, so we said we want the patient. So then we want them to have it for 10 days. This prescription only goes to day eight. So we're gonna have to go, we don't, we don't, we don't go down and start and start on down here, we go across the page. Okay. So instead of doing it for day eight and then having to rewrite it completely, we can just, we can just skip that page entirely and we can start writing it here and you'll notice that this has got a lot more space. So when we know that we're confident that this is the antibiotic we want to use. This is where you're going to be writing it. Okay. So it will look like this. So date oral doses, make sure you take the box is the drug name, the indication how many days you've given it for. We're now circling micro advice and signing a day together. Okay. So again, I've crossed out the morning dose on the 18th and I've gone all the way up to the 10 days and I've drawn a line and then I just said stop after the 24th of the 5th, 23. Okay. And then I signed that as well. Just so they make so that they know that it's me. He's done that. You don't have to do this. You could just put a little box here and say review on that day because you might want to continue it. You never know. But this is roughly what you want to do. Okay. So I would recommend doing it this way. So you don't have to rewrite if you write it like this, you end up going to have to rewrite just two days on this bit. It's a bit pointless. Are there any questions about that? I realize that's quite a lot of information to dump at you. Any questions about antibiotics and how and how the pages work? Yeah. Okay. If you think of any just don't make. So next, we're gonna look at regular medications. So most drug charts again, not every drug that's going to look like this, but once you've got, you've got your antibody, your acute meds, your antibiotics, then you're going to start with your regular medication. So it's going to look like this. Um, on this drug chart, we have a little section at the top for vte prophylaxis. So, pretty much every patient in hospital as I'm sure you guys will know is given some kind of prophylaxis. Um So my trust it is enoxaparin. Um, but I'm not going to cover that now because it's very different and actually where I trained in Leicester in England, um, we never had a page like this, so I'm not going to go into it. You're, it's very self explanatory and it's just like normal. It's just that's specifically the place where you're going to be putting your vte prophylaxis. Okay. So here's some examples of some very typical regular medications that you're going to be seeing. So you've got aspirin 75 mg once daily. Trim bo that's an inhaler. Uh and it's, and you'll see 100 and 72 slash five slash nine micrograms. That's just the dosing of the various components. Two puffs twice a day, Metformin 500 mg, twice a day, levothyroxine 100 micrograms. Very important once morning. Okay. So this is what it would look like written on the chart. So if you take aspirin, so very self explanatory date route dose ticked when I want it aspirin. This here is quite small. So I'm sorry if you can't see it. So, on our drug chart, it says medication reconciliation. It's basically means did we start it? Is it continued or have we changed the dose? Okay. So these, I'm going to suggest that these are all continued and I've signed it and dated it very self explanatory Trumbo. So the inhaler, you'll notice it. So it's inhaled iron. H and I put a special instruction, wash slash rinse mouth after use. That is because this has got a steroid in it into your risk of thrush. So always write things like um wash your mouth out, signed and dated it the way that we, right. So rather than because this is technically the dose rather than writing all of that in these tiny little boxes, I just put it in brackets here. So every single dose, every single puff they're getting that dose. And then you can, you see this random little symbol I've done down here. Some of you may have seen this before. Some you might not have. This is a really useful symbol that we use for when it's, it's kind of a nondescript version of one of something. So one sachet of of of a medication, one puff of an inhaler. OK. So it's a T symbol with a dot at the top that means one to tease next to each other with two dots, right? We've got here. That means to and you can basically keep going, keep going, keep going. You could have five capital T s in a line with five dots at the top and that means five of something, okay. So they're gonna have two puffs in the morning and two puffs at bedtime. That Foreman very similar to the asthma in very, very straightforward date time, dose drug name. No, special instructions here, you could say with food. If you wanted, you don't have to and the levothyroxine. So you'll notice here, I've put, I've actually written out micrograms. This is what I would recommend. You guys do. Milligrams are kind of the default micrograms. You do not want to get them mixed up. Hopefully most people and most experienced nurses will know that you don't give levothyroxine in milligrams, the doses that they will have it available in like the tablets will not like they'll have to give tons in order to get 100 mg of levothyroxine. So they'll probably query it but make sure you just write out micrograms just to avoid any confusion. Okay. So I have had to go into the second box, but it's worth it for keeping things very, very clear there. Also notice that you're here. So special instructions 30 to 60 minutes prior to food, such other medications continued that okay. So you don't have to. So all of these little boxes here, pharmacists, a really, really good job of mopping up after, after, after the doctors. So if you haven't written something like this, which is fine if you haven't. Um, but the pharmacist will go and write something down. So they might say before other medications or, you know, if it's a bisphosphonate, sit up after having it, things like that, they'll write it down over time. You'll get used to which medications you need to put a little caveat with and this is the sort of thing you'll see. Okay. So, a little bit of a, a little question. Yes. So, also pharmacists you'll realize. So, nurses are amazing. But pharmacists are your absolute best friends and they have saved me a few times since starting work. So, every day a pharmacist will review every single patient structure and it's mainly they'll look at, um, so all these little like random and pharmacist it's here. That's for them to check that. They, they have a supply of the medication on the ward. So things like Aspirin, Metformin, they'll have them trim but other ones, they might not have the levothyroxine in that does and in that ward. So they need to check it. Let me Yeah, sure. So um but yeah, so pharmacist always check it. They will query things with you if they think things are weird if you've given something that counteracts something else. Um So for example, um I gave a patient so a patient had COVID on award the other day and we gave a drug called PAX COVID. Um The first time I'd ever heard of it's, that's given the drug and I prescribed it. And the pharmacist found me later and said we can't actually give, we can't give an ox aspirin or a picks back. We can't give this blood thinner with this medication. And I said, okay, that's fine. Didn't know that. Cross off. So they will catch things for you obviously don't just rely on them really good. The pharmacists. Um, so someone then said, can you say again what the medicine reconciliation boxes? Okay. So that's this little box here. It's not on every drug chart. So I've trained in, I've done some training in places where they don't have this box, but this is essentially. So if you're copying from someone's drug chart, what they're having, uh, sorry from their GP records, you're going to write this word here. You can't really see it was quite small. This says continued. Okay. So you're gonna circle continued because it's a medication that came in hospital on. If I've, if I've got a patient, I'm starting on Aspirin, I'm going to circle started. So anyone so let's say this patient comes in hostile know vte prophylaxis whatsoever and I start them on enoxaparin. I'm going to be circling started. Okay. You'll see the use of those changed in the next slide. Who supplies the drug pharmacist? So nurses the ones that give the drug. But pharmacists, you have a pharmacist and you have pharmacist technicians, they go around and make sure that the ward has a supply of all the drugs they need. Okay. So it's the pharmacist that do the ordering of the drugs. Can you clean the dots and teas? Yeah. So I don't know how uh use a piece of paper. So um yeah, so the dots and the teas. So as I said, so a capital T like this with the dot On the top means one of something and it's, it can be used for a sachet. So like uh lactulose comes in a sachet. Um So you can say one sachet and you just use that dot T with a dot At the at the top, you can use it for inhalers. So puffs um rather than writing two puffs, you can just write like this symbol that I've done down here nine line. So think of it like two capital teas sitting right next to each other and then two dots above. Okay. And you could do far, you could do a really long line, five lines coming down. So five teas all sitting in the line and five dots above that would mean five or something. It's unlikely that you're going to want to get on five puffs of an inhaler. But you could do that. Does that make sense? Hopefully? Ask, ask me again if you have any more questions? Um, just like, yes. Yeah, they are. Um, and, but even if you go to a place and maybe they do it and someone says, what is this? You know, maybe maybe they have not seen it before you can teach them or if someone says we don't use this, then just don't use it. Um, but certainly where I've worked and where I trained and here people use it. Okay. No ways. So, okay. So, so we've had that drug chart, we've written up all our meds for our patient. So after two days, the nurse informed you that the patient has been having that Metformin as it wasn't the correct dose. So the patient is actually on 1 g, twice a day, not 500 mg twice a day. How do you change the drug chart? Say this is what it's going to look like. So I've put a neat cross. So I'm not scribbled it. How I just put a really neat cross. You can still see what was written and, and then I put the new date. So it was two days data. So almost 17th Orel, I'm signing in this tiny little dot tiny, tiny little space. This is why it's really important to have a really small signature. Um And I put the new doses in. Okay. If the patient, if the patient wasn't having a medication, they probably should, the nurses will have been putting a symbol here. So if the patient's refusing the medication, most drug tracks on them back, we'll have some space for um, if the patient. So there's basically non administration codes. So if they haven't had it and they put a code to, that means the patient wasn't on award to have the medication if it means um, like, so number four, if it would probably the the nurse would probably put a four here because the patient is refusing it because it's not the right dose. Okay. But if you were so I've just put lines here for now, but I've made it really clear boxes over where I want them to go. So. Oh, sorry. So you can see at the top I've written in the dates and go. Oh, we're down, follow the 17th, all the way down. Yes, I want these ones given on the 17th. Okay. Does that make sense? Any questions about changing doses or wish? Oh, and so what I would, what you might do. So, I still say I've still circled continued because it was supposed to be on. But if the patient came in and this was their regular medication, they were supposed to go on 500 we decided to increase the Metformin. I'm gonna cross out this continued. I'm going to circle dose changed and I'm going to do an up arrow just to symbolize that we are increasing the dose equally. If we're decreasing the dose we're going to put down arrow. Does that make sense? Okay. Let me again. Stop me if you have any questions. Ok. Prn medications. So, in the drug chart we've seen, we've got the acute medications, we've got the antibiotics, more antibiotics, regular medications, regular medications, another page of regular medication. So, in these drug charts they have a space for, I think it's 20 regular medications. Um, you'd be surprised some people do have more than that and it takes an absolute age to write out the drugs but at the back you'll find usually 1 to 2 pages of PRN medications, prn meaning um as required a donut. Uh I think P R N is Latin for something. If I'm honest, I don't know, you don't need to know it just means as, as needed. So, examples, analgesia think that paracetamol codeine morphine antiemetics, cyclizine on Dan's Itron metoclopramide, anything like that. Antidotes naloxone. Very important and then inhalers. So people that, yeah, so you're not a regular inhaler like your trim bow just just as needed inhaler and you put your DTN sprays as well. Okay. So this is this is where you're going to see that stuff. Uh There's, there's a lot, a lot, basically any medication that can be regular, you could also write as as required. Most some meds like Metformin, you're not going to put as required, but in theory, you could put any medication here. So this is my top tip for you guys. So unless contra indicated if you are in A and E or am you or any kind of acute ward where you're clerking a patient and writing their drug chart for the first time or even if you're rewriting the drug chart, always put some kind of analgesia. So usually paracetamol as some kind of anti sickness, usually cyclizine or Ondansetron, whatever you want to use, put them in the P R N, even if there's no indication at that point for it, it will save you time. Okay. So you'll, you won't be called back later to be like, oh, doctor, the patient suddenly felt sick or the patient suddenly has a bit of pain in their knee. The nurse will just see it in the drug chart. Perfect. Give it done. Okay. Saves you time. Trust me. Um, a little, another thing that I haven't written down is naloxone. So hopefully we can anyone tell me what naloxone is or what it's, what's the antidote for opioid? Yeah. So it's, it's opioids. So, if you are writing morphine anywhere on the chart, usually more you, you probably see morphine in the P R N is quite regularly. If you are writing morphine, you must, right? Naloxone. Okay. Do not, do not prescribed morphine without prescribing naloxone. That is something that island since working. Okay. I wasn't taught that at med school but it's really important that you have a, yeah, that you give an antidote. All right. Let me make a lot of good question. But it was super efficient is protein woman who gets overnight. So if it's, uh, if it's on the regular and they've already given it that day, they can't give it, if it's not written on the P R N S, they can't give it. So if, for the nurse to be able to give it whenever or within reason whenever, um, they can't give it. Yeah. No prescription. No drug. The nurses will not give it and sometimes they might even call you even if they haven't written up there might be like, can I just check something? But, so I'm just going to move this blinding this. Okay. Okay. So can you give a couple of examples we tend to? Uh, yeah, so other things. Okay. So you're being bleeped. I mean, you're honest, those are your main ones. Anti, um, painkillers, just paracetamol. You know, you don't want to give someone prescribed morphine that's a bit rogue. Um You want to give anti an antiemetics, an anti sickness and a pain killer. Um You could prescribe DTN spray, but that may be might be a bit weird. Um You could, if you think people are appropriate and it's safe, you could preserve, you could prescribe something like copy clone. So a sleeping tablet because on nights you do get called quite a lot for people to have a sleeping tablet. And occasionally if you maybe have a patient that's quite agitated, you could be because you could prescribe something like the Raza palm or diazePAM. So you could give something like that if you wanted. Um But most of the time nurses aren't going to give that without checking with the doctor first because you can't just go, you know, if a patient gets agitated or it's annoying on the ward or is yelling a little bit because maybe it's got delirium. You don't just go straight for, that's chuck a load of drugs at them a laxative. Yeah, laxatives. A really good example, actually. Good shout. Uh Yeah, wack a laxative on then why not? Obviously, every time you're prescribing things. So make sure you're not going for something that's contra indicated. So, um if the patient's got Ronnie diarrhea, you're not going to be prescribing a laxative on the P R M. It's not simple. So naloxone is for whenever you're prescribing morphine. So the question is, is naloxone for when you prescribe regular morphine or just if it's PRN, anytime there's morphine on the drug chart, if it's regular or PRN you need to prescribe naloxone. PRN. So the naloxone is just for, and you'll see on the, I think I've written on the next slide just for when the patient's respirator is below eight or they have a really low gcs. Okay. So, it's only if we think we've accidentally overdose them. Is this, this is the chart the same for critical care. Yes. So, in our store, at least it is. So these medication, um, it's because it's the doctors using them, they're the same, the news charts and the nursing charts that you see in things like I T U R different because they have their own individual. They're like huge pieces of paper and they're actually quite weird to read. But the drug chart certainly they're the same. Um, okay. I think that's all the questions now. Okay. Right. So, here's some examples of some PRN medications and how are you sorry how you want to prescribe them. So um just so you know, so these little boxes, this is this row, that's one row for giving one dose. That's another row for giving another dose. So they have 123, six, so 18 top so 18 doses can be given before you need to rewrite it. Ok? So date put the drug name, the dose. So for Percy to wants 1 g, this is something. Don't worry guys, on your first day, you're going to check this 1000 times. You know, it's 1 g, but you're going to check the B N F and you'll check it for the first couple of months. I'm not confident enough to know that it definitely is 1 g and it's okay to prescribe without looking at the B N F. But there's no shame. I look in the B N F all the time. Okay. So doses 1 g route. So with prn medications you can write all slash IV. Gosh. So I just really long time as oil slash IV. Um generally try and avoid it but particularly something like cyclizine. It's almost throwing up actively. You're not going to say it will take a tablet, you're going to give it IV. But most of the time some says, oh, I feel a bit sick. You want to encourage them to take all if we can avoid giving something IV, we want to give it orally. Um Yeah, so this is this little dr means hourly, so four hourly. Um and the max dose is four times a day, okay, indication pain fever. This is the same reconciliation thing we saw earlier. Started, continued dose changed. Okay. Um Any questions about this, here's the dot symbol again. So thi so that's 1 to 2 and because it's salbutamol, this is 1 to 2 puffs, it's inhaled, they can have it as and when it's a shortness of shortness of breath and wheeze your no difference here between these two. So this is just an inhaler. This is a salbutamol neb. So the dose NG is different, okay, 2.5 to 5 mg, you can get away with giving these kind of vague doses on the P R N Z. Okay. But the indication for these are the same naloxone again. Yes sir. Here. So reduce respirator rackets less than that we could have eight or thrush opioid overdose. So here I've had to write out slightly differently. So one minute intervals as needed. Obviously, you're only giving IV and this is micrograms. I've written M C G. I haven't written out my micrograms purely because I don't have room but just make sure that see how that see is really obvious. Okay. Any questions about this? No, okay, right. Insulin, this will, so insulin chart look like this, they fold out and they're huge. Okay. So very similar to the other charts, stickers, details of stay number of charts. So this will be charged if they yes. And this, this is gonna be chart number one, this is chart number two. It doesn't matter which way around there. Acute doses of insulin, very rare to be giving these and prn doses again, very rare. So I'm not really going to cover these. So this is what the inside looks like if you can get hold of a chart like this, have a look at it, read it because this information here is really, really useful and it looks a bit overwhelming, but just take it home, sit down and read it on one of your first days. It's great. So this is the area slightly different to a normal drug chart. It's a lot longer. Um And you'll see there's a lot more type, a lot more chances for us to rewrite the doses. And that's because we do alter insulins quite a lot. And as I said, so the back, this sort of black, this white and red is where we right in the blood sugars, okay, that nurses will be checking. So I'm really sorry for the quality of this photo, but so patient's name, hospital number filled out all that. So the date here, it just asked for my initials. So Milly Abbott. Oh, sorry. Um my sleep number and then I take breakfast and dip supper, 10 units in the morning, 12 units at supper, HumuLIN M three, the strength. Make sure you put this in, this will be on their drug chart. This will be on their GP record. Okay. And ideally put the device as well. There's lots of different devices. You've got flexi pens, quick pens, all kind of other, always good to write down what it is. Um The patient should know what they're on if they're too unwell to tell you, it should say in a clinic letter or something somewhere um that you will be able to find it. You might just have to do some digging. Okay. So these are some. So this, so we've got this patient, we're giving Cumulus M three which is a mixed insulin. So it's got a short acting and an intermediate acting. Okay. We're giving it twice a day. 10 units in the morning, 12 units at night. These are the blood sugars for two days, have a little look at those. So these are the times these are the doses, times doses. So 15th 16th, what's the issue here? Uh Nice. Yeah. Okay. So someone's already and Andrew's already jumped ahead to my next question. But yeah, so um yeah, too high in the morning, aren't they? So we've got our, this is our be be before breakfast is 21 it's 23 the next day around lunch. It's kind of coming down a little bit because you know, we've maybe the insulin that we're giving here is starting to work a little bit that's bringing it down and then it's okay that it's kicking up a bit here because this is our, usually before tea time eight is absolutely fine. Um, maybe a little bit on the high side, but then they eat dinner, I'd expect it to go up a little bit. That's fine. Well, it's not fine but I'll allow us. So, yeah, these ones are too high, what we're gonna do about it. So, what do we need to do these with the insulins? Perfect good. So a lot of you really have recognized that we need to change the evening dose, not the morning, we change the evening dose because this is the one that is then affecting the morning blood sugars. Okay. So again neat lines crossing that out, keep in the morning we're going to up it by two. Okay. So the target, as I'm sure you guys know is about 4 to 7. If it's an elderly or very frail patient, we might go for a slightly higher or broader target because we don't want to risk them dropping into a hypo. So you might, you could, you might tolerate maybe a 5 to 10, a lot looser, okay? Um So when you adjust the insulin, you need to think about what type you're using. So are you just using, using actor rapid which is happening right then and there in which case you need to adjust if it's, if you're taking the blood sugar after dinner and you're only using a really insulin, you need to change that insulin, but we're using an insulin that is intermediate. So it's working over a 12 hour period. So obviously that's why we're changing the one that was 12 hours before. So when increasing the insulin, usually the rule of thumb is 10% up or down. I've got the app so 10% up and down, but also take that with a pinch of salt for, for F ones, I would say usually go with two units. Um You don't want, if you're more experienced, then you could be more aggressive with it. But we don't want to be too aggressive because you know, we were just having a little play with their insulins. Um If someone's on like 88 units, which I have seen and these are big people who are incredibly insulin resistant, um then going up from 88 to 90 is going to make pretty much no difference. So you want to get, so in those situations, you'd be going up by 4 to 6 units at a time. Okay. So still not quite 10% because go up by eight units is quite a lot. But if there were on 88 units, you might go up by say 6 to 90 for any questions about insulin. Very Woan Tour, right? I was gonna suggest a little break because I realize I've just thrown a lot of information at you, but I've also realized what the time is um do we want a break? I don't know. Ok. Okay. If you think we should have a break now or um just crack on. Yeah, I think we can just crack on. Yeah. Okay. So. Oh good. Let's keep going. So types of fluids now if you're not on, so I would take photos of these because you're going to need them for some questions. So fluid that most of us will be familiar with sodium chloride and then you've got the half a half bag which is 0.45%. So employed which is which is that dose, dextrose 5%. Hope you should get. You should guys should have heard of that. And Hartmann's, these are typical ones. So I'll let you guys should take a little photo of that quickly. Okay. And then these are slightly more out. They're not out there but less common drugs, um bags that I prescribe and not all wards are going to have every single kind of fluid. So you'll see sometimes. What's that? Yep. Sure. I'll go back. Um um So yeah, one ward might have 0.9% but they might not have 0.45%. Okay. Right. Plasmalyte. Some places love it. I've literally never, never ever prescribed it. I've never prescribed the sodium 0.1 sent, I only prescribed dextrose 5% dextrose 10%. Um and sodium chloride 0.9%. That's all I prescribed in my in Hartman's actually occasionally Hartman's but usually those, those are the only ones I'm looking at. Okay. So maintenance fluids. So daily requirements. Does anyone know how much fluid we need every day? This is the maintenance. Mhm. Good. Yeah, perfect. So every day we need 20 to 30 kg per at mills pack A G. So it depends on the person. Good. Uh What about sodium? So the main electrics were worried about our sodium um chloride and potassium. So what how how much do we need per kilo per day? Perfect. Oh Giving you that one. Yeah, there you go. So one minimal of sodium, one minimal potassium, one millimeter of Floyd and you need 50 to 100 g of glucose every day. And that's everyone, obviously everyone's on the site different spectrum, but generally everyone needs 50 to 100 g, which is quite a big window to be honest. So some examples. So you've got a 55 year old, let's say it's a man 55 year old who weighs 100 and 1 kg and is nil by mouth. What is the maintenance, maintenance, fluid requirements? So, so have a little thing in your head. How much fluid do they need? How much sodium in they're going to need? How much chloride do they need? How much potassium do they need? And how much sugar do they need? Okay, give you a little second just to think about it. It's not So using those numbers, we just have to think about. So fluid wise they all you're doing is 100 and one times 25 to 30. So 2525 mils to 3030 mils, glucose is 5200 and sodium chloride or potassium at just 100 101 miles. Okay. So using the photos that you took them and I'm I'm gonna let you guys have a little think about what you would give in a day. Okay? So 24 hour period, that's what they need. How, what would you guys like to give? Have a little think. Um I will warn you this. I try to make them as easy as possible, but none of the answers are going to be perfect. My, my answer is not perfect and that's okay. Just get roughly in the ballpark. You just don't want to give an absolute ton of something and nothing of something else. Okay. So how are we going to get that? I'll give you guys like a minute. There's not much more after this. So. Mhm. Right. Just in the interest of time. I'm just going to move us along. Um So this is a drug, this is what the fluid looked like. Oh, we'll give you the answer in a second. So we've gone through all the drug chart at the very, very back by the PRN side. We have the fluids, okay? You can find fluid prescriptions just by themselves, but you need to stick them or attach them somehow to the drug chart. But this is what blank ones going to look like. So this is what my answer was. So this is what I prescribed and I'll go through it in a second one. Need to. Yep. Good. Okay. Yeah. So someone put some answers in. So I've gone for 0.45% sodium chloride one liter. So again, just, just literally following. So yes, you, you can add, you can add potassium to dextrose. Yeah. And if in doubt ask um so in so we're going to give the strength and the types that always put these, you can put normal sodium. But if you're gonna put normal sodium, that's our normal saline. Put 0.9% as well. You can't, don't just right normal saline. So always specify the percentage because I'm giving a different type one liter IV you can write potassium chloride out if you want or you can track KCL and just put a line to make sure no one adds anything. I made a little mistake here. That's okay. Just put a neat line through it when you make a mistake and right dose. So the dose of the medication we're adding is 14 minimal. This symbol again, this means hourly, eight hourly and I prescribed and I've signed it. I look, I do a little one. I want the patient to have 22 bags of this. So prescribe it to into initial if continuous. So I put my initials here and I put one bag to bag and I've crossed out the space for the third bag. I don't want them to have a bad dextrose with nothing else in it. And I've crossed out those two lines and just said that and I haven't put my initials here because I don't want them to have it. Okay. Uh Yeah, so most of the time um yeah, they'll have bags with potassium pre added. They don't really like to add potassium to it. So sometimes you'll ask for 20 million mole and they'll say we only have the 500 mil bag. So you just have to change the prescription and right to 500 mil bags with the potassium because they might not have one liter bag with the potassium on the ward and that's it. So, but yeah, they usually you can add it but they typically come premixed because it's just easier and more secure. Yes. Um So do you need to document in the notes that you prescribed? Yes. So I would, I would document that. You prescribed fluids. You don't have to necessarily put exactly what you've put. You could just put one liter of sodium with potassium. You could put that if you wanted, we're not documenting, you're revising with that. So, no, you don't have to. Um I do typically because if you don't, so if you just take this second chart here. Um, and I haven't, I haven't, I haven't put my initials here. The nurse will only give one bag. I specifically want them to give two bags. So I will put numbers next to it to say this is bag number one. This is bag number two. If you're maybe over the weekend, you want a patient have a continuous fluids, you're gonna write 123412. So 123123. Ok. So just keep going. But if it's not low, so it is dangerous potassium if it's not too low, but this is maintenance. So this patient is not eating at all. So they need as a maintenance they need to have for this patient 100 and one moles of potassium every day. Okay. Which seems like a lot. Um So we're too bad. Uh uh 2000 eventually. Yes, probably. I can't remember. What is it in it? Too honest. Um So I'll go through what I've so again. So I was sat there and I tried to make this as simple as possible and it's actually really difficult. So the bag one, that's what I'm giving bag too is exactly the same bag three. Is that so total, I'm giving three liters and they needed just, they needed between 2.5 to 3 liters. So that's good tick. They needed 100 and one miles of sodium potassium and chloride as, as someone pointed out, you know, you don't want to give, you don't want to overdose someone on potassium. So I've heard on the side of caution and I've given two bags of 40. So they're only getting 80 mg of potassium, which is okay. Um I have, they've got a little bit, they have got more sodium employed than they need, but it's unlikely to, you know, it's not going to affect their sodium hugely. Okay. Obviously, if it did, you'd address that, but it won't okay. And then they're getting that glucose. That might not be enough for someone who's 100 kg. But you know, as I said, it's not an exact science. It's not perfect. It's the last time too. Yes. So I could, I could have, I could have given it um in that bag, I think to find a 5% dextrose with 20 millimoles of potassium would probably quite a weird not weird bag. But you, you learn what is normal on your ward and what isn't? And I've just from experience um typically most wards don't stop dextrose with potassium. You can mix them, but they don't typically mix them. So most of the time if you're adding potassium, you're adding it to a sodium chloride bag because that's just what they have on the ward that stopped, but you cannot. Okay. So, right. Just another one quickly. Um So 90 year old, let's say this is a woman, 90 year old little looked frail old lady, 45 kg, she's only be able to tolerate steps of water. What is her maintenance fluid? Uh Oh, someone's asked me to repeat what I said about. So people couldn't have a little think about this while I'm answering this question. So, um the patient's of this case, 1 55 year old, they needed 100 and one minimal, minimal of potassium every day. Um It's for maintenance, so I'm not replacing, I'm not trying to top them up for them thing. I'm just keeping it a level so it's dangerous to give them too much. And I, so I've heard on the end on the side of caution and only given them 80 minimal is just because it was a nice round, forget to give two bags of 40. Um Someone pointed that I could have added up another 20 and made it 100 which, which I could have done. But just because I know that bags aren't that common to find dextrose with potassium. I didn't add that but it's fine to give 80 as long as you're, you're going to be monitoring their bloods anyway. So you'd be checking, they're using these daily and if they needed to see um replacing, you could then address that. But to give 80 millimoles in 100 and 1 kg, it's fine. It won't like that, but it's not, it's not like if you don't give someone 100 in a day, they're gonna suddenly drop their potassium down to to it's not going to happen. It will, the body can adapt. Okay. So I bought a clip. So the case to the fluid. So again, 45 times 25 to 30. So a lot less fluid this time, but the same, same glucose and they only need 45 minimal, so less than half. So have a little think about what you'd want to give them. So it's going to look quite different. Okay. Also, I'm sorry, so that we won't, this won't be much longer, maybe like another five minutes. Um Obviously, if you need to go, I appreciate that you need to go. Sorry, that's running over slightly. There's any few more slides. So I've just the blue box is just covering up what I wrote before. So not to confuse you. So this is what I went for. So you can see this time. I've only gone for one bag each. So I haven't done any initials. I think the email, I think the feedback form is going to be emailed at the end with this presentation as well. So date, I put sodium chloride 0.8% and the dextrose one liter and here I've only given a 500 more bag have given 40 millimeters of potassium. I've given it over 10 hours. So the reason why I've done that. So um sorry, right. So this bag 500 mils. So typically you give bags over like 8 to 10, 8 to 12 hours. This is so I think the other bags I gave over eight hours, but this is a lot smaller. A little old lady. We don't want to give her a massive liter in. Even though 8 to 10 hours isn't huge difference. I'm not going to pump her through full of fluid really quickly. So I'm going to delay that one hour bag over. I could even, I could have even given it over 12 hours to be honest, okay, just to really draw out. So she's not being pumped full of fluid. Um and then I gave the same bag but a smaller dose and I didn't have any potassium. So bag one looks like this bag to looks like this. It's basically half and bag. So the totals I'm giving slightly over the fluid that she needs, which is why I need to be careful how quickly I'm giving it. Um almost bang on sodium and chloride, potassium pretty close and she's having 60 mg 60 g of dextrose. So this is actually a lot easier to get quite close to what she needs. Um Any questions about this one? Okay. Yeah. So you could give a 2 50 mil bag. Absolutely. If you wanted. Um I just went for 500. Um you could, you could even give her one. She is sipping water depending on how much she is sipping. If she's having literally just sips, then you would, we might go over. Um, but if she's actually, you know, she's having quite a few cups of tea in the day you could get away with maybe just giving her one beater and she can top herself up with the rest. Um, so final preflight. So top tips, it doesn't have to be perfect. I promise you. I did not understand flowed, prescribing pretty much until I started working. Um, yes. Yes. It's not an absolute science's. You just want to make sure that you're not pumping someone full of potassium or something like that. That's more the potassium that you want to think about and then just keep an eye, keep an eye on the using these. Those are the important things. So always check for fluid overload with that 90 year old. He's 45 kg check that we're not overloading her with fluid. Is she looking really puffy? Um or even the 100 100 kg man. Does he have heart failure? Things like that? So they go this checked for reasons for reduced fluid alliance. Does the patient have heart failure? Are they really fluid overloaded? Um Other things like that? Okay. Um one liter at a time. So this is more for well. So I have prescribed them altogether. But ideally, you want to prescribe one liter at a time and go back and re evaluate okay, you don't want to just give someone three liters and walk away because three liters is a lot and only a huge person can take that on. Okay. And when in doubt asked, I asked my seniors all the time to check that my flute that are happy with my fluids. And sometimes I will, I will prescribe something that I think is like perfect. And then there'll be a lot more slapdash about it. And that's fine because they're older, they're more experienced, they are willing to accept the risk of maybe not giving exactly, you know, the calculations, whereas I might spend a bit more time calculating it. Exactly. And that's okay. Okay. So if you are replacing and maintaining, so replacing is the most important thing, festival. So this is more like a Reece um resuscitation situation, slightly replacement versus resuscitation, slightly different. But replacing would be like if so, for example, today I had a patient whose potassium was 2.5. So I was going to get. So I gave them sodium chloride with potassium and that's me replacing them because they are eating and drinking. But I gave them a bag, one liter of IV fluid with potassium to replace what they weren't what they were lacking. Okay. Um That is not a maintenance. They didn't need that bag of fluid, but they needed the potassium. Okay. So um yeah, you always replace first and then you only give them maintenance fluids. If someone is not eating and drinking, if someone's eating and drinking, they don't need maintenance fluids. Okay. Um, don't just give fluids for the for the sake of given fluids if that makes sense. Okay. Perfect. Ok. I think this might be maybe the final slide. Okay. Yeah, so just really quick on recess fluids. Um okay. So quick fire questions guys. So we've got a patient that comes into a and they've got really, really low BP. Let's say it's 70/50. What you're gonna do like just showed you down to the. So we're gonna give fluid and what kind are we going to give anyone there? Oh, stunning answer. Very nice. Yeah. So typically we're going to give normal Saline. So that's 0.9% normal Saline. Which and how much are we gonna give someone's already given an answer that so we're going to get 500 mils out standard. So, um I'd because most people maybe who are over like 50 kg are going to get, they're going to get 500 mils. Obviously, you hopefully you guys know this. If there you're going to get 250 mils, if they're very small, if they're very frail or if they are overloaded. So the difficulty is when you have a patient coming in who has a really, really low BP, but it may be in heart failure and maybe coming with decompensated heart failure and you're kind of stuck in this. Oh gosh, what do I do? I need to offload them, but I also need to give them fluid to bring that BP up. It's a bit of a tight line to walk. Ask casino if you're not sure. Okay. But 2 50 mils if you're not sure. So let's say the big BP rises, what we're going to do. Okay. So we're gonna start maintenance fluid until the patient is eating and drinking independently. So they come in maybe, I don't know, they were, I don't know. Example. Yeah, they come in, they have a really, really low BP maybe cause they're septic. Maybe it's like the patient we gave Amoxicillin two at the beginning, really low BP. We're gonna give her some reset them, them, some resuscitation fluids and then as soon as they are able to eat and drink again, they don't, they don't need anything but we might put them on summation in fluids in the meantime, to keep their BP at that level. But we're not giving them aggressively fluids. We're gonna give instead of 500 miles over 15 minutes, which is stacked. We're going to give a liter over eight hours. Okay. Um So the BP drops or the BP stays exactly the same. What do we do? Mhm. Okay. We're going to repeat our bags. We're going to keep giving fluid. Does anyone know what the limit is? How much fluid do we give? Yeah, perfect. Two liters. So don't give any more than two liters without seeing a senior. The next thing is to get help. Okay. So if someone's blood push, if you pump someone through, I mean, you're going to be getting help before two liters, to be honest, because if guys going in over 15 minutes, you're not gonna wait an hour with, with a low BP before you get help, but do not give more than two liters in a recess situation without a senior telling you to do so. Okay. Right. Um Just a really quick slide on e prescribing some places in England particularly do e prescribing. It's online. It's incredibly simple. It's way easier than this. You also don't have to do a lot of thinking because as long as you know, the drug you want, you type in the drug, it brings your drop down menu, you pit you write your indication and usually it will say um it will give you a space and it will give you all the formulation. So if it's um I don't know, Metformin, it might give you 500 mg or might give you a 1 g tablet and it will show you all the different doses you can give, you just click on it. You say how many times a day and it will often bring up alert for you. So if you're trying to give morphine and the patient's already prescribed codeine, it will bring up an alert and say, are you sure? And you can just override it or you can say no I don't want to do that and you can take it off. This is as good a picture as I could find on the internet about an example of it. But essentially it is so much easier than this. So, if you're going to a place that does e prescribing, don't worry about it, it's way easier and they'll have, um, they will have, um, tutorials on how to do it. Okay. Right. Any questions, sorry that we've run over. So, yeah, 11 minutes over any questions? I don't know. Coco, can you answer that? Where can we get access to the recording of this session? Yes. So you will receive a notification about the recording and the slides after you fill in the feedback form and I'll just send the feedback form again. Mhm. Hopefully you guys got something out of that. Um, it's very long and a lot of it you will pick up when you're working. Um, it's okay to make mistakes. Pharmacists are there to pick up on your mistakes. Nurses are there to pick up on your mistakes. Nurses are really experienced if you don't know where to prescribe something, nurses will probably be able to tell you because they're the ones who use these. So if you're like, oh, I'm giving this medication, don't know where to put it. They'll be like, oh, usually it's here like nurses know pharmacists. No more senior doctors know. Just ask, it's fine in August. Literally everyone is like running around like a headless chicken. It'll be fine, right? Um Is potassium usually given with one liter bag. Um No, but you can't give more than 10 minimal per hour of potassium. So you could give a 500 mil, a 500 mil bag with 40 millimoles potassium. But you'd have to give it over four hours at least. So it's typically given in a bigger bag so that it's run over a longer time. If that makes sense, you just don't want to give, you can't give more than 10 minimal to potassium in one hour. So it's easier to put it in a bigger bag any more questions. Nope. Perfect. Okay. And stop the recording for now.