Caregiver Ebook

Caregiver Training Ebooks

The caregiver training e-book gives a training course on how to provideassistance to another person who is ill, disabled or needs help with daily activities. It can also serve as a useful guide to the individuals in the need of help. The product deals in physical, mental, social, and psychological needs and well-being of both the caregivers and the elderly person requiring care. Everyone needs a little help from time to time and while many seniors lean on the friends and family members for support, there may be some instances in which it's necessary to seek additional assistance or long-term care which was why this product was created by the author. This caregiver product is a practical guide created by the author who is an expert in the field. This product embeds in it several training sections in which each section gives detailed information on how to provide assistance to people who are ill, disabled, or aged. This product is a trusted and 100% guarantee to provide the necessary details needed in caring for the physically challenged, aged and ill individuals. The product is also an essential overview of issues from Alzheimer's to diabetes to strokes. Read more here...

Caregiver Training Ebooks Summary

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Author: Kenneth Watts
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Series Editors Introduction

The editors have chosen the most well-recognized and respected authors from around the world to contribute the 22 informative chapters. Key features of this comprehensive volume include an exhaustive list of more than 30 pages that provides the reader with the only documented information on the carbohydrate and calorie content of hundreds of commonly used drugs. This is a critical and excellent source of detailed information that is required by parents and caregivers to accurately calculate the intakes of patients on the KD who also require medications that could affect the diet's efficacy. The editors have also included a list of reputable resources on the KD as well as epilepsy that is invaluable to both the patient and health professional. A significant resource for families with children that have seizure disorders is the Charlie Foundation. The founder, Jim Abrahams, Charlie's father, has provided an Afterword at the end of this volume that traces his...

Current Concepts and State of Knowledge

Adolescent neurodevelopment involves changes spanning multiple spheres of higher order central nervous system function and anatomy, including those that subserve cognition, emotion, and motivation (Romer and Walker 2007). Cognition in childhood, initially dependent on concrete interpretations of the physical world, and yet prone to fantasy and make-believe, becomes increasingly efficient and accurate with respect to classifying and predicting complex contingencies. Emotions are used less unidimen-sionally for engendering caretaking or exploring relationships with specific caregivers. They become more complex, and at times volatile, both for asserting independence from caregivers, and for experimenting with and learning effective emotional conduct across a potentially large variety of peer and other social relationships spanning diverse personal and occupational domains (Nelson et al. 2004). Motivation becomes extremely sensitive to novelty and social competition, especially with...

Postanalytical Considerations

The clinical laboratory can provide real-time notification to the patient care personnel as well as the project personnel from the test action limits that are built into the clinical trial laboratory database through automated and manual processes. The laboratory must assume responsibility for communication with the patient care personnel as outlined in the protocol and supporting documents. In a high-throughput automated facility, the laboratory must have a process where critical patient safety information is conveyed directly to the caregiver with positive confirmation that the information was received. By providing realtime feedback through the reporting process, the clinical laboratory becomes an essential communication link in successful biomarker data delivery. The reliable delivery of laboratory test results and associated flagged results is a critical element ensuring patient subject safety. The central laboratory with congruent global databases is capable and critically...

Pain And Suffering What Are They

A clinical definition of suffering, in addition to acknowledging threats to the self from incoherence and helplessness, will need to account for an elusive quality within suffering that resists any probe that seeks to lay it bare to objective analysis. Pope John Paul II acknowledged this elusiveness when he wrote about the oppression of mind and spirit'' that often accompanies pain. Suffering encompasses, like pain, an irreducible subjective dimension, but it is distinctive in shattering the norms of life in which even pain can be understandable and thus bearable. For contemporary philosopher Emanuel Levinas, suffering is the impasse of life and being'' what he calls the explosion and most profound articulation of absurdity.''45 We must not expect a crystal clear account of suffering when it constitutes an experience that plunges our most basic assumptions about life into utter chaos and absurdity. Suffering is like a text that suddenly plunges into an unknown language -or outside...

Overview and Pathogenesis of Alzheimers Disease

Alzheimer's disease is a devastating illness. It occurs mainly in the elderly population. Once afflicted, Alzheimer's disease produces progressive and unrelenting damage to the human brain. The average lifespan after being diagnosed with this illness is about 8-10 years 1 . Patients steadily lose cognitive functions including memory, executive functioning, and the ability to care for themselves. In addition, behavioral symptoms of agitation, depression, and psychosis are often co-morbid with Alzheimer's disease. This devastating illness affects not only the patients but also the families and anyone that provides care for them. In the United States, the staggering financial cost of the disease accounts for nearly 100 billion per year in medical and custodial expenses, with the average patient requiring about 27000 per year for medical and nursing care. Furthermore, 80 of caregivers of patients with Alzheimer's disease report stress, and about 50 report depression 2 .

Overview of Cholinesterase Inhibitors in the Treatment of Alzheimers Disease

The use of cholinesterase inhibitors may preserve activities of daily living, slow progression of memory loss and improve behavioral and cognitive symptoms associated with Alzheimer's and related dementias. Treating Alzheimer's disease often takes great patience on the part of physicians as well as patients and caregivers. Response to drug may take weeks, sometimes months before caregivers may notice a difference in symptoms, if at all. The efficacy produced by cholinesterase inhibitors is not always clear-cut. For example, there is some evidence that donepezil may benefit moderate to severe Alzheimer's dementia in outpatients, however, the results have been conflicting in the nursing home population 17 . In addition, both donepezil and galantamine have not yet shown consistent results in improving behavioral and psychotic symptoms in patients with Alzheimer's disease. Improvement in psychosis is seen with rivastigmine which has shown improvements in behavioral symptoms in mild to...

Chemistry And Formulations

DOSAGE AND CLINICAL USE The induction dose, onset, and duration of anesthesia are similar to thiopental (Table 13-2). Dosages should be reduced in the elderly and in the presence of other sedatives and increased in young children. Because of its reasonably short elimination t1 2, propofol often is used for maintenance of anesthesia as well as for induction. For short procedures, small boluses (10-50 of the induction dose) every 5 minutes or as needed are effective. An infusion of propofol (100-300 ,ug kg min) produces a more stable drug level and is better suited for longer-term anesthetic maintenance. Sedating doses of propofol are 20-50 of those required for general anesthesia. However, even at these lower doses, caregivers should be prepared for all of the side effects of propofol, particularly airway obstruction and apnea. Propofol elicits pain on injection that can be reduced with lidocaine and the use of larger arm and antecubital veins. Excitatory phenomena during induction...

Incorporating Creativity into Ketogenic Diet Meals

Creative meals can be designed to provide variety, such as tacos made with an egg-white shell, pizza made with an eggplant crust, and spaghetti squash with a tomato-meat sauce. The heavy cream can be prepared in different ways. It can be whipped and served with fruit, mixed with diet caffeine-free root beer, or thinned down with water to resemble milk. Creative ideas for ketogenic meals often come from caregivers who are eager to make the diet more interesting.

Use of Donepezil in the Treatment of Alzheimers Disease

The efficacy of donepezil in Alzheimer's dementia has been demonstrated in several trials. In a study by Rogers and colleagues, the efficacy of donepezil in treating patients with mild to moderate Alzheimer's disease was investigated in a randomized, double-blind, placebo-controlled, fashion. Patients were followed for 24 weeks followed by a 6-week placebo washout period. The primary efficacy was measured by the Alzheimer's Disease Assessment Scale, cognitive subscale (ADAS-cog) and the Clinician's Interview Based Assessment of Change-Plus (CIBIC plus). There was statistically significant improvement in cognition in patients who were on donepezil versus placebo at the end of 24 weeks. After the 6-week washout period with placebo, there was no difference in the scores from both groups. This suggests that donepezil improved cognition in patients while they were taking the medication, but if stopped, the improvement in cognition might be reduced to minimal. Patients in this study...

Ketogenic Diet Therapy Followup Program

Management of the ketogenic diet is best achieved through phone calls and regularly scheduled follow-up appointments with the ketogenic diet team. Phone calls at least weekly with the dietitian during the early weeks of this therapy are vital to the success of this therapy. A 1-mo visit after ketogenic diet initiation followed by a visit every 3 mo is commonly practiced. At each visit the child's seizures, growth, and neurological and nutritional status are evaluated. The initial laboratory studies are repeated at each visit to monitor metabolic responses. Caregivers are asked to keep a journal of seizure activity and ketone readings to facilitate objective decisions regarding therapy adjustments.

Causes and Treatment of Behavioral Changes

Summary This article describes Alzheimer's disease as an increasingly common management concern for primary care physicians. Although little can be done for the primary symptoms of the dementing process, the secondary behavioral complications of this illness may be amenable to behavioral or pharmacologic manipulation. Agitation may be responsive to environmental or psychosocial intervention. Treatment with low doses of antidepressants can improve depressive symptoms. Mild anxiety is best treated with emotional support from the family and caregiver. Benzodiazepines can be used with caution. Insomnia can be reduced by encouraging a routine that prevents daytime napping and keeping the patient busy during the day. Pharmacotherapy for disturbed sleep often causes more harm than good and should be avoided if possible. 3 references. (AA-M).

Outpatient or Inpatient Initiation of the Diet

There has been much discussion lately about whether it is safe to initiate the diet outside the hospital setting. Our feeling is that in certain circumstances it is possible and safe, and we have begun several patients on the KD as outpatients. Sometimes an insurance company will not cover the KD even when deemed medically indicated. If the patient has responsible caregivers, no medical contraindication, no history of status epilepticus, and is at least 8 yr old, we consider initiation of the KD on an outpatient basis. In such a situation, the physician, nurse, and dietitian are available around the clock for the first few nights to take calls from the family. Typically, the patient is fed enterally or has been on the diet before.

Marital Couples and Family Therapy

Another potential stressor is that normal interests (e.g., in outside hobbies and activities) may no longer be available to the patient, partner, or other family members. Social support networks that would normally be relied on might be less accessible. The patient and his or her primary caregivers may have little emotional reserve remaining to support and care for others within the family.

Customized Patient Medication Packages

In lieu of dispensing two or more prescribed drug products in separate containers, a pharmacist may, with the consent of the patient, the patient's caregiver, or a prescriber, provide a customized patient medication package (patient med pak).1 It is the responsibility of the dispenser to instruct the patient or caregiver on the use of the patient med pak.

Radioimmuno Conjugates

Radioimmuno-conjugates use monoclonal antibody to target radioactive particles to tumor cells (Tables 51-3 and 51-4). 131Iodine (131I) is a commonly used radioisotope the gemission of 131I can be used for both imaging and therapy, but releasing free 131I and 131I-tyrosine into the blood presents a potential health hazard to caregivers. The p emitter, 90Yttrium (90Y), is an attractive alternative to 131I, based on its higher energy and longer path length, which may be more effective in tumors with larger diameters. It also has a short t1 2 and remains conjugated, even after endocyto-sis, providing a safer profile for outpatient use. However, disadvantages include its inability to image, limited availability, and expense.

Pain Assessment in the Elderly

The assessment of pain requires time and patience. Thorough history and physical examination are a crucial part of the assessment. First interview should focus on vital signs, state of hydration, and conversation style of the patient. If these patients are confused or show memory deficit or incoherent speech, then bedside psychological tests should be done to diagnose cognitive deficit. Elderly patients who have difficulty communicating with clinicians are at particular risk of under treatment (Bernabei et al. 1998, Pargeon and Hailey 1999, Fineberg 2006). Detailed chronological history may be collected from the patient, previous medical records or if patient shows memory difficulties or uncooperative behavior, direct interview of family members or caregivers residing with the patient. Systematic physical examination of body should be part of the pain assessment protocol. As most elderly patients suffering from pain are on multiple medications, adverse drug interactions should be kept...

Rational Design of Protein Hormones Tomorrow Is Here

The introduction of new versions of rapid-acting recombinant insulin prepared by introducing modifications in the insulin sequence has decreased the time from injection to insulin action, allowing for an insulin injection at the same time as a meal 17 . Insulin lispro and insulin aspart are rapidly acting forms of the hormone that can be given at mealtime or even after a meal. The latter approach is especially important in managing an infant or young child with diabetes as the caregiver can adjust the insulin dose to the child's actual food intake 18 . A new analogue, insulin glargine, appears to solve the problem of peaks and troughs of insulin action following NPH or UltraLente injections 19 it provides nearly constant levels of insulin action, similar to physiologic insulin secretion 20 .

Pre Ketogenic Diet Session

The rigors of ketogenic diet management should be discussed during the pre-keto-genic diet session. The process of food preparation and food weighing should be explained. The caregiver should be provided with the information for purchasing a scale that weighs in tenths of a gram (0.1 g). A description of the typical meals and beverages, and the requirement for the omission of carbohydrate-rich foods, should be clearly communicated. The caregiver should be informed about the appropriate foods and nutritional supplements that must accompany the diet. The follow-up appointments required to monitor the diet safely should be reviewed. The caregiver should understand the possible adverse effects of the diet, including constipation, kidney stones, and difficulty with compliance (particularly with older children). The expected length of keto-genic diet therapy should also be reviewed in this session. Eating is an activity that is highly celebrated in our society with every holiday and major...

Second Generation Antipsychotics

Monitoring of patients receiving psychotropic medications for weight and metabolic parameters is crucial. The report from the Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes Consensus Panel contains valuable advice for appropriate and prudent monitoring 45 . The most frequently assessed parameter in the recommendations is weight. At a minimum it is obtained at baseline, monthly for the first 3 months, and then quarterly. However, monitoring weight at each and every patient visit will allow the clinician to catch a problem early, before substantial weight gain has set in, and underscore to both the patient and the clinician the importance of physical fitness. Additionally, patients and or caregivers can be educated about monitoring weight and report back to the clinician.

Fine Tuning the Ketogenic Diet

The goal of ketogenic diet therapy is to find and maintain a state of ketosis that serves to abate seizures. After a few weeks of ketogenic diet therapy, a defining pattern of ketosis will emerge. Ketosis is monitored at home by the caregiver with a urine ketone testing kit. Ketosis is usually lower in the morning and higher in the afternoon and evening. Urine ketone levels are a crude estimate of serum ketone levels and can be sufficient for determining level of ketosis on a daily basis. P-Hydroxybutryate is the serum ketone that is thought to impact seizure control and can be measured quantitatively by blood analysis. A P-hydroxybutryate level may be helpful when attempts to fine-tune the diet by means of urine ketone levels are inadequate. Diet manipulation can alter ketosis and effect seizure control. Several factors should be considered before deciding how to adjust the ketogenic diet. The initial goal is to ensure that 100 of the ketogenic diet is being consumed. This may take a...

The Treatment of Pain

Clinically, pain can be described as a complex construct, integrating the physiologic, mechanical, and neurochemical responses with the social, behavioral, and psychological responses to noxious stimuli. It is therefore necessary to recognize myriad approaches to the treatment of pain and to assess and treat the patient within a larger biopsychosocial view. The choice of a given course of therapy for pain, therefore, is often more dependent on the beliefs of the caregiver and the prevalent world view of his her place and time. Through history and continuing today, pain therapies have ranged from religious and spiritual practices, cognitive approaches, behavioral therapies, and pharmacotherapy, to highly anatomically specific treatment. As the adage goes, a chance to cut is a chance to cure, requiring that the medical caregiver believes that the nature of a pain lies in the body. Inspired by specificity theory and its derivatives, more and more refined specific anatomical treatments...

The Specialty and Future of Pain Medicine

Pain is essentially so much a part of our common humanity and so central to the practice of medicine that without understanding of the assessment, diagnosis, and treatment of pain, our care of patients would be woefully inadequate. The dramatic breadth and depth of the field of pain medicine makes it a fertile ground for future innovation. In every aspect of pain care, from the subcellular to the community-wide level, advances are being made that not only influence theory but also practice. The rapid current acceleration in molecular biology, genetics, imaging modalities, and high technology provides constantly growing potential for discovery. At the same time, renewed interest in old world ideas and techniques encourages the development of the art of healing among caregivers. It is the goal of this chapter to provide a mental framework to understand the evolution of our current concepts and therapy for pain and to foster professionalism in this newly emerging and exciting focus of...

Introduction The Need for Historical Perspective on Pain

The importance of recognizing, assessing, understanding, and treating pain is central to the role of any caregiver. When a patient presents to the physician, he rarely comes labeled with a given diagnosis rather, he more often has a chief complaint that he suffers in some manner. To the patient, the symptom, not the pathology or disease, is the affliction. As such, it is imperative that we respect and understand that pain and suffering are the often primary reasons that patients seek medical care for.

Options for Pain Management

The amount of pain experienced by women in labor is hard to predict. Some have tolerable pain while others may benefit from some form of analgesia. Many non-medical techniques can help deal with the pain of labor. The choice of analgesic techniques is between the patient, obstetrical caregiver, and when applicable the anesthesiologist. Again, both the ACOG and the American Society of Anesthesiologists (ASA) jointly opine that maternal request is sufficient medical indication for pain relief during labor. It is only the choice of analgesic that is made in conjunction with the medical team providing care to the patient.

Use of Galantamine in the Treatment of Alzheimers Disease

In one of the earlier studies investigating the efficacy of galantamine in mild to moderate Alzheimer's patients, Tariot and colleagues enrolled 978 patients in a randomized, placebo-controlled, double-blind trial. Patients were randomized to receive either placebo, or galantamine doses of 8, 16, or 24 mg per day at the end of 8 weeks. Among the scales used to measure efficacy were the ADAS-cog, the Clinician's Interview-Based Impression of Change plus Caregiver Input, Activities of Daily Living, and the NPI. After following the patients for 5-months, the investigators noted modest but statistically significant efficacy across all outcome measures in patients who were receiving 16 mg or 24 mg day compared with placebo. The 8 mg day group did not separate from placebo. The 24 mg day group did slightly better than the 16 mg day, however, the difference was not statistically significant. In this study, galantamine was also well-tolerated, there was no difference in the discontinuation...

Drug History

The starting point in the drug history is the documentation of current prescription drug use. It often is very helpful for patients to bring all current medications with them to the clinical encounter. Specific prompting is required to elicit the use of over-the-counter drugs and herbal supplements. Similarly, information about medications that are used only sporadically (e.g., sildenafil for erectile dysfunction) may not be volunteered. With cognitively impaired patients, it may be necessary to include caregivers and pharmacy records in the drug history process. Adverse reactions to drugs should be documented with specifics regarding severity. It is revealing to ask whether patients or their physicians have discontinued any medications in the past. A review of current drug profile and list of adverse effects are required for each patient encounter, both during hospital rounds and during outpatient visits, to maximize effectiveness and safety of treatment.

Calculating Fluid

Adequate fluid intake is necessary to maintain normal hydration during ketogenic diet therapy. Insufficient fluids can increase the risk for kidney stones and constipation. The ketogenic diet restricts fluids to noncaloric, caffeine-free beverages such as water, decaffeinated weak tea, and noncaloric caffeine-free soda. Fluid should be calculated for the maintenance needs of the individual. The Holiday-Segar Method is a fluid calculation that is based on weight alone (6) (Table 11). This formula does not account for abnormal fluid losses, for example, from excessive drooling or febrile illness. For example, a child weighing 23 kg needs 1000 mL (for first 10 kg) plus 500 (10 kg x 50 mL kg) plus 60 mL (3 kg x 20 mL kg) for a total of 1560 mL daily. This can be divided into six servings of 250 mL as a simple daily guide for the caregiver to manage. The child should not be allowed to drink large volumes of fluid at one time because this may upset internal fluid balance and ketosis. The...

Sick Days

The caregiver must also receive counseling on management of intercurrent illnesses ( sick days ). If the child is vomiting or has diarrhea, ketogenic meals should be temporarily stopped and the emphasis should be on maintaining hydration with fluids. Diluted broth, noncaloric caffeine-free soda and sugar-free gelatin can be offered. If vomiting and or diarrhea persists, an oral rehydration solution may be given at half-strength. Easy-to-digest ketogenic meals such as ketogenic eggnog or chicken salad with applesauce can be restarted in half portions when the child is ready to begin eating. The signs and symptoms of hypoglycemia and excessive ketosis should be taught during the hospitalization, and the method of treatment should be outlined for home use. A visit to the pediatrician or emergency room may be necessary if symptoms persist after treatment. Caregivers should be assured that these problems are unlikely to occur once the child has begun to consume the full diet. Close contact...

Hunger Behavior

Caregivers often feel that they are starving their child because of the limited volume of food that the diet provides. Some children will become upset that they are not allowed additional servings of food when their meal is completed. The caregiver should be taught to maximize the quantity of foods by using the higher volume vegetables (group A) and fruit (10 fruit). A small spatula should be used at each meal to ensure that every morsel of fat and cream (which tends to adhere to dishes) is consumed. A free-food snack can be provided daily to lessen hunger between meals. Chewing on ice chips or drinking allowed fluids may also delay appetite. Feeding the child his or her meals at evenly spaced intervals throughout the day will assist with hunger management. If hunger behavior persists, the caregiver should discern between true hunger and manipulative behavior. One approach is to remove the child from the eating area as

The Dietitians Role

The most important member of our ketogenic diet team is the dietitian. Our dietitian is employed by our Epilepsy Center, a private clinic, rather than by the hospital, thereby assuring that she does not have conflicting responsibilities. Other centers need to utilize dietitians whose duties are shared by other clinics and by inpatient units. Based on the dietitian's workload, we have found that we can initiate and follow a maximum of one to three patients per month, also dependent on the needs of the patient and the abilities of the caregivers.

Fine Tuning the KD

Second, it is not trivial to locate all the items in a meal plan. Recently the US Food and Drug Administration ruled that carbohydrates (CHOs) need to be listed on food packaging only if they comprise 1 g or more per serving. This allows manufacturers to label many products that contain a small amount of CHO as carbohydrate free. Also, many products are labeled incorrectly. Thus when a specific product is purchased that is outside our experience, it is essential that the dietitian or caregiver call the manufacturer to get the exact product specifications.

Case

The clinician must identify alternatives at this crucial moment. At the same time, this patient must remain connected to the primary physician or oncologist because of the progressive nature of the pain problem and the likely need for opioid and other aggressive analgesic measures. From the classification scheme of CAM therapies, one can rule out movement-based therapies and manipulative therapies, which would certainly aggravate bone pain. The goal for a complementary or alternative therapy may be to manage nausea rather than pain since some opioid is likely to be needed no matter what alternatives are applied. Acupuncture has been shown to improve nausea in several controlled trials in a variety of settings, including nausea due to cancer chemotherapy. It may be worthwhile to offer it for opioid-induced nausea. Acupressure can be applied more frequently at the same well-defined point on the volar aspect of the wrist (P-6) by a caregiver or by using a wristband with a pressure bead...

Side Effects of AEDs

Most AEDs are tolerated well in monotherapy. The risk of side effects increases with polytherapy and high therapeutic dosing, which are the clinical situations frequently encountered in patients with intractable epilepsy. Both a history of poor tolerance and the appearance of significant side effects from AEDs are strong considerations in deciding whether to use the KD. In contrast to AEDs, the KD appears to improve both cognition and behavior in children. This KD-associated improvement has not been thoroughly studied but is often reported by parents and caregivers prior to discontinuation of the AEDs (20,33).

General

The disorders of pancreatic cancer, chronic pancreatitis, IBS, and IC have been presented as archetypal examples illustrative of most of the problems facing the clinician in the diagnosis and management of this type of pain. In the case of pancreatic cancer, we have a disorder that has definable histopathology, is accepted as pain-producing by all caregivers, and elicits intensive and aggressive treatment. Palliative surgery, high dose narcotics, and therapeutic interventions such as neurolysis are considered standards of care. This contrasts with IC and IBS, disorders for which reassurance and watchful waiting'' are considered appropriate care, with aggressive treatments reserved for the patients who complain loudest and longest. For these disorders narcotics have been viewed as controversial at best and contraindicated in many patients. Chronic pancreatitis is somewhere intermediate to these other disorders in that definable pathology is present but this pathology does not correlate...

Cancer Related Pain

Death distress is usually more profound in young patients and appears to be inversely correlated to spiritual groundedness (Chibnall et al. 2002). Differing spiritual beliefs between the caregiver and the adolescent patient can be a cause of worsening distress. Health professionals are encouraged to be familiar and non-judgmental of spiritual or religious beliefs of their patients (Lyon et al. 2001).

Affective Disorders

Occurs only after long disease duration, and with very marked neurological deficits, and is part of an 'organic psycho-syndrome' caused by extensive cerebral lesions. Even in very disabled MS patients, this type of mood does not occur in more than 10 . Anosognosia (a lack of insight into the disease) may be a blessing for severely disabled patients and their care-givers. It is, however, as rare as euphoria in early and middle phases of the disease.

The Ketogenic Diet

Peterman and other pediatricians eagerly acted on Wilder's suggestion (34,35). Peterman first reported the calculation and effectiveness of the ketogenic diet from the Mayo Clinic in 1924 (35). Peterman's ketogenic diet, composed of one gram of protein per kilogram of body weight in children, 10-15 g of carbohydrate per day, and the remainder of the calories in fat, is identical to the ketogenic diet that is used today. Peterman documented the importance of teaching the caregivers management of the diet before discharge, individualization of the diet, close follow-up, and the potential for further adjustments at home. He also made the early observation that excess ketosis could lead to nausea and vomiting, symptoms that were quickly relieved by orange juice (34). This clinical caveat is still useful to know and is employed as needed during initiation of the ketogenic diet (36).

Constipation

Guidelines for constipation management should be discussed with the caregiver, with the emphasis focused on prevention. Adequate fluid intake and the inclusion of vegetables into daily meals may be enough to prevent constipation for many children. Adding up to 25 g of iceberg lettuce as a free food to the diet may also help. Calculating 10-20 g of avocado into a meal for daily consumption may also promote regularity. Some children will need further dietary manipulation such as the calculation of medium-chain triglycerides (MCT) oil into meals. Pharmacologic intervention with a carbohydrate-free stool softener may also help to prevent constipation.

Questt

When obtaining the patient's history, the interview of both the child and the par-ents caregivers is essential as children 5 years of age and older may be able to describe and portray their pain experience more accurately than their parents as parental perceptions, biases, and personal needs may be reflected in the parents' depiction of the pain history. The clinician should also be aware of the cultural beliefs surrounding the child's pain experience, the potential for secondary gains, and the overall family dynamic between the child and parent caregiver when obtaining a complete history. The OLDCARTS mnemonic is often a useful guide when conducting a pain-specific history

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