DOCSLIB.ORG

Mouth Care – a Quality Improvement Project

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Mouth Care – a Quality Improvement Project Mouth care – A Quality improvement project The Hundred House, 10 May 2016 Dr Matthew Doré What is a Quality improvement project? An audit has the audit cycle to measure what we do against defined standards. Not everything has standards defined, has unclear or no guidelines, Some of these things would improve quality of patient and staff with general common sense A QI projects allows incremental and measurable changes to make a difference to patients’ care • More flexible and dynamic, • if something does not work to scrap it • employs multiple changes Dry Mouth (aka Xerostomia) Highly prevalent symptom in palliative care. Incidence of 60-80% in patients with advanced cancer (PANG 2011) Risk factors include… 1) Medications 2) Mouth breathing 3) Advanced age 4) Previous history of radiation to the head and neck 5) Sjögren’s syndrome (the SICCA syndromes) 6) Diabetes mellitus (or vascular diseases) 7) Anxiety states 8) Dehydration Medications "Medications seem to be the significant cause of Xerostomia in palliative care” - (1) “A median number of four drugs they were associated with xerostomia" - (2) “Dry mouth can alter taste and make it difficult for patients to eat and swallow and may also complain of mouth pain and difficulty with speaking” – (2) - ? Swallow tablets , eat / drink effectively 1) Davies AN, Broadley K, Beighton D. Xerostomia in patients with advanced cancer. J Pain Symptom Manage 2001; 22:820. 2) Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp Palliat Care 2000; 17:118. • Xerostomia is a significant problem for many palliative patients, with an incidence of 60-80% in patients with advanced cancer and those being admitted to hospice units (PANG guidelines 2011) • NICE highlights that when managing xerostomia in a palliative population individual patient preference is likely to influence product acceptability and compliance (NICE 2012 Palliative Cancer Care - Oral). • A Cochrane review on the interventions for management of dry mouth (which was not specific to the palliative care population) did not identify any strong evidence that any topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al 2011) Literature Search • There are to date no randomised controlled trials demonstrating a superiority of any individual mouth care products or oral saliva replacement products to each other in a palliative population. • Systematic literature review: Xerostomia in advanced cancer patients (Supportive Care in Cancer, vol 23(3) Oct 2014). • The aim of this review was to determine the effectiveness of pharmacological and non- pharmacological interventions in treating xerostomia in adult advanced cancer patients. • Systematic literature review: Xerostomia in advanced cancer patients (Supportive Care in Cancer, vol 23(3) Oct 2014). • Results : – 3 RCTs and 3 prospective studies. – Compared acupuncture, pilocarpine, Saliva Orthana and chewing gum with placebo. – All interventions were considered effective in treating xerostomia, to equal effect. – However, effectiveness versus placebo often could not be demonstrated statistically significantly. – No meta analysis possible. – too small • Conclusion: – Limited published data exists so no firm conclusions can be drawn. – However, pilocarpine, artificial saliva, chewing gum and acupuncture have 'some' evidence. – This highlights the explicit need to improve our evidence base. Properly constructed RCTs are required. • Palliative Medicine as a whole recommend a variety of oral saliva replacement products and mouth washes for the management of xerostomia, often based on familiarity and ad-hoc experience rather than guidelines or evidence. • Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of mouthcare products and contrasted our current clinical practice before trying the products and after. (approx 60 different health care professionals tried the products) Before and After: Top 5 & Top 3 Top 5 rankings Top 5 rankings Top 3 rankings Top 3 rankings before after before after Oral balance Biotene Oral balance Biotene (Biotene) gel (47) moisturising (Biotene) gel (33) moisturising mouthwash (36) mouthwash (29) Biotene Sugar free chewing Biotene Sugar free chewing moisturising gum (35) moisturising gum (21) mouthwash (35) mouthwash (30) Glandosane Salivix sugar free Glandosane Oral balance (natural) spray (34) pastilles (30) (natural) spray (16) (Biotene) gel/Sips of water (16/16) Sugar free chewing Oral balance Sips of water (13) Salivix sugar free gum (24) (Biotene) gel/Sips pastilles (13) of water (25/25) Sips of water (21) Sugar free chewing gum (9) 29/5/15 and overall dryness score 2/6/15 13 overall 10 dryness patient score COB 0 MG 4 8 RM 4 overall dryness score KS 5 DF 5 5 GS 5 EH 6 SM 6 EM 8 3 MG 8 MP 9 AM 9 0 FH 10 COB MG RM KS DF GS EH SM EM MG MP AM FH Mean 6.2 Removed 4 patients, 2 could not respond, 1 0 – not dry - normal inappropriate, 1 confused 10 – as dry as can be Mouthcare Pre Patient Biotene Nystatin Salivex other COB 0 0 0 0 MG 0 0 0 0 RM 0 1 0 0 KS 1 0 0 chewing gum DF 1 0 1 0 GS 0 0 0 0 EH 1 0 1 Daktarin SM 1 1 1 0 EM 1 1 0 0 MG 0 0 0 0 MP 0 0 0 0 AM 1 1 1 0 FH 1 0 1 occasional lollies 7 4 5 Most had no product 13 It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland, Bedford, Cambridge, Shrewsbury I searched and collated other sources of information and guidelines on Xereostomia, including… 1) PCF5 (p599), 11) Addenbrooks - Good oral care 2) Dental and Oral Care chart (RVH), 12) BMJ – oral care 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool, 5) Oxford handbook on Palliative Care, 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol Failed flow diagram 16 It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush, management of painful mouth and Denture care. These aspects where all inseparable Issues raised and noted.. 1) Difficulty diagnosis of thrush (? coating) 2) Denture care (using toothbrushes, masking thrush/ulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once / day 5) Unclear guidelines on painful mouth The guideline clearly also had to incorporate and clarify these aspects Petroleum Jelly and Oxygen This myth is based on the National Fire Protection Association's (NFPA) 1996 edition of its Standard for Health Care Facilities, which states, "Oil, grease, or other flammable contaminants shall not be used with oxygen equipment" (item 8-6.2.2.2), and "Flammable and combustible liquids shall not be permitted within the site of intentional expulsion" (item 8-6.2.2.3). There is no evidence of any danger 1) Winslow EH, Jacobson AF. Dispelling the petroleum jelly myth. AM J Nurs1998:98(11):16) 2) Phippen ML. Is petroleum jelly safe? AM J Nurs 1999: 99(8):24 3) Woodrow P. Petroleum jelly myth. Nurs Older People 2004: 16(6): 41 Are there any adverse incidents reported in the literature? There are NO case reports of adverse incidents with Vaseline applied to lips 1) Ocak I1, Raffensperger J, Turkbey B, Fuhrman C. Lipid pneumonia secondary to Petroleum jelly use in a patient with tympanic membrane perforation. JBR-BTR. 2009 Nov-Dec;92(6):280-2. 2) Gorospe L1, Gallego-Rivera JI, Hervás-Morón A. Exogenous lipoid pneumonia secondary to Petroleum jelly application to the tracheostomy in a laryngectomy patient: PET/CT and MR imaging findings. Clin Imaging. 2013 Jan-Feb;37(1):163- 6. doi: 10.1016/j.clinimag.2012.02.002. Epub 2012 Jun 8. Is there a fire risk? There have been some reports of surgical ignitions of various materials such as Chlorhexidine and Tracheostomy plastic. These took place in a surgical setting with high concentrations of oxygen and with a clear ignition source, most commonly diathermy / cauterization. NOT Vaseline! 1) Gorphe P1, Sarfati B2, Janot F2, Bourgain JL3, Motamed C3, Blot F3, Temam S2. Airway fire during tracheostomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2014 Jun;131(3):197-9. doi: 10.1016/j.anorl.2013.07.001. Epub 2014 Apr 1. 2) Bengezi O2. Third-degree burns caused by ignition of chlorhexidine: A case report and systematic review of the literature. Plast Surg (Oakv). 2014 Winter;22(4):264-6. Vo A1, Vaseline is flammable right? The Material Safety Data Sheets by Sasol demonstrate the flash point of petroleum jelly to be around 150 degrees Celsius and an autoignition temperature of around 320 degrees Celsius. This is way above normal environmental encounters and consistent with plastics considered very safe. (For example Polyvinyl chloride (PVC): Flash point 250 degrees and Ignition temp 450 degrees) 1) Sasol Material Safety Data Sheet – Petroleum Jelly Revision date 11/4/2011 Created by B.Shamase approved by Ephraim Papo Petroleum jelly without oxygen - blow torch https://www.youtube.com/watch?v=8hAUKTnHlcg Petroleum jelly mixed with oxygen - blow torch https://www.youtube.com/watch?v=yLqixjvTD7s Oxygen Tubing https://www.youtube.com/watch?v=asumR-n2e6k Ignition with lighter Ignition with blow torch Petroleum jelly on Melted, never ignited Melted, 120 seconds to it own ignite Petroleum jelly Melted, never ignited Melted, 111 second to mixed with oxygen ignite 10min (high flow) Cotton wool on its Ignition 3 seconds, burn Ignition instant, burn time own time 45 seconds 40 seconds Cotton wool mixed Ignition 11 seconds, Ignition instant, burn time with petroleum jelly burn time 197 seconds 113 seconds Oxygen tubing Ignition 18 seconds, Ignition instant, burn time burn time 10 seconds 8 seconds A lot of resistance… Why? In gathering the opinions of 52 carers and nursing colleagues in Bedford Hospital, Addenbrooks and Sue Ryder Hospice in relation to the use of petroleum Jelly with oxygen the following concerns were highlighted: 1) Risk of blame if anything untoward happens, 2) Potential to be told off by seniors, 3) Must not challenge policy even if I personally disagree, 4) The change would not be sustained by my colleagues.
Load more

Recommended publications
  • Revised 6/1/11 1 INDEX Books on Child Care...4 Care of the Newborn
    Revised 6/1/11 INDEX Books on Child Care ......................................... 4 Fever… ............................................................. 14 Care of the Newborn......................................... 4 Feeding ............................................................. 15 Dosing Charts for Medication............................ 23 Head Injury........................................................ 16 Well Child Evaluations & Immunizations........... 7 Headache.......................................................... 16 General Information .......................................... 2 Jaundice............................................................ 16 Kidney-Urinary Problems ..................................16 COMMON MEDICAL PROBLEMS Lumps, Lymph Nodes, & Kernels...................... 16 IN CHILDREN Mouth Problems ................................................ 17 Poisoning .......................................................... 17 Allergies, Recurrent Colds, & Ear Infections ..... 8 Rashes… .......................................................... 17 Attention Deficit Disorder (ADD or ADHD) ........ 8 Scabies and Lice............................................... 18 Antibiotics.......................................................... 9 Sore Throat ....................................................... 19 Bed Wetting ...................................................... 9 Spitting Up......................................................... 5 Bites… .............................................................
    [Show full text]
  • ILEX Skin Protectant ILEX SKIN PROTECTANT Is A
    DESCRIPTION - ILEX Skin Protectant ILEX SKIN PROTECTANT is a topical skin barrier for use on intact or broken skin, a variety of dermal wounds and stomal irritations. Ilex adheres to moist weeping wounds to form an occlusive barrier against urinary and faecal material, digestive enzymes and wound exudates. Ilex is alcohol free so it is safe to use on all skin types, from babies to the elderly. Ilex can be used in conjunction with other prescribed treatment such as topical steroid and antibiotic therapy. • Helps maintain a moist environment that maximizes healing with a unique 0.00cm/hr MPR (moisture penetration rate). • The occlusive barrier formed by the paste helps to prevent external microbial filtration and therefore helps prevent infection. • Adheres to moist weeping tissue (broken skin) using copolymer bioadhesives which forms an occlusive barrier - particularly effective against digestive & urinary acids and wound exudates • Soft, flexible and easy to apply - minimises pain and disturbance to wounds. • Inert and non-toxic; contains no alcohol or latex and is not absorbed systemically so it’s safe to use on fragile skin, paediatric and elderly • Bio-compatible with medical and surgical devices and ostomy appliances • Ilex may be used in conjunction with prescribed topical agents such as antifungal and antibacterial. INGREDIENTS Calcium/ Sodium PVM/MA Copolymers, LiquiparPE, Cornstarch, Zinc, Sodium Carboxymethyl Cellulose, Petroleum jelly INDICATIONS: Prevention and treatment of a wide range of skin irritations and excoriations due to: • Skin irritation and breakdown, caused by urinary and faecal incontinence. Ilex provides an effective barrier against the devastating effects of urine and faeces. Ilex contains no alcohol, and will adhere to denuded weeping tissues, without discomfort to the patient.
    [Show full text]
  • Salicylic Acid
    Treatment Guide to Common Skin Conditions Prepared by Loren Regier, BSP, BA, Sharon Downey -www.RxFiles.ca Revised: Jan 2004 Dermatitis, Atopic Dry Skin Psoriasis Step 1 - General Treatment Measures Step 1 - General Treatment Measures Step 1 • Avoid contact with irritants or trigger factors • Use cool air humidifiers • Non-pharmacologic measures (general health issues) • Avoid wool or nylon clothing. • Lower house temperature (minimize perspiration) • Moisturizers (will not clear skin, but will ↓ itching) • Wash clothing in soap vs detergent; double rinse/vinegar • Limit use of soap to axillae, feet, and groin • Avoid frequent or prolonged bathing; twice weekly • Topical Steroids Step 2 recommended but daily bathing permitted with • Coal Tar • Colloidal oatmeal bath products adequate skin hydration therapy (apply moisturizer • Anthralin • Lanolin-free water miscible bath oil immediately afterwards) • Vitamin D3 • Intensive skin hydration therapy • Limit use of soap to axillae, feet, and groin • Topical Retinoid Therapy • “Soapless” cleansers for sensitive skin • Apply lubricating emollients such as petrolatum to • Sunshine Step 3 damp skin (e.g. after bathing) • Oral antihistamines (1st generation)for sedation & relief of • Salicylic acid itching give at bedtime +/- a daytime regimen as required Step 2 • Bath additives (tar solns, oils, oatmeal, Epsom salts) • Topical hydrocortisone (0.5%) for inflammation • Colloidal oatmeal bath products Step 2 apply od-tid; ointments more effective than creams • Water miscible bath oil • Phototherapy (UVB) may use cream during day & ointment at night • Humectants: urea, lactic acid, phospholipid • Photochemotherapy (Psoralen + UVA) Step 4 Step 3 • Combination Therapies (from Step 1 & 2 treatments) • Prescription topical corticosteroids: use lowest potency • Oral antihistamines for sedation & relief of itching steroid that is effective and wean to twice weekly.
    [Show full text]
  • Use of Petroleum Jelly to Improve Surgical Mask and Eyewear Associated Skin Irritation and Fogging
    Volume 26 Number 12| December 2020 Dermatology Online Journal || Letter 26(12):22 Use of petroleum jelly to improve surgical mask and eyewear associated skin irritation and fogging Brett C Neill MD, Edward W Seger MD MS, Jace Rickstrew MD, Anand Rajpara MD Affiliations: Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas, USA Corresponding Author: Brett Neill MD, Division of Dermatology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, Tel: 913-588-3840, Fax: 913-588-3995, Email: [email protected]. Keywords: COVID, PPE, personal protective equipment, skin outcomes can be achieved through behavior irritation, goggles, petroleum modifications such as educating health care workers to expect mild skin irritation, utilizing prophylactic dressings, and often finding alternative personal To the Editor: protective equipment (PPE), [2]. Although many of There is a high prevalence of skin irritation, these options are effective, they are not always particularly of the nasal bridge and cheeks, realistic options for busy health care workers. We associated with prolonged surgical mask and goggle present a simple solution using petroleum jelly to use. We present a simple solution using petroleum minimize some common adverse events associated jelly to minimize this irritation. Using a sterile cotton- with prolonged surgical mask and goggle use. tipped applicator and a single-use petroleum jelly pack, apply a layer of petroleum jelly to the entire Solution interior aspect of the nasal bridge portion of the Most disposable surgical masks contain a nasal surgical mask, taking care not to contaminate your bridge reinforced with semi-moldable material protective equipment.
    [Show full text]
  • Mouth Care for Chemotherapy Patients
    Mouth Care for Chemotherapy Patients Chemotherapy (chemo) treatment may affect your mouth. Please use the information here to help manage mouth care. Possible Problems Chemo may cause the following: Sores (ulcers) in the mouth or throat. Infected sores. Painful mouth and/or gums. Burning, peeling or swelling of the tongue. Changes in consistency of saliva. Dry mouth. Changes in taste. Painful swallowing. Difficulty eating and talking. You can see or feel most of these problems. Check your mouth every day. Mouth Care Ideally, visit your dentist a month or two before starting chemo. Inform your dentist and oncology team if you’ve had mouth or dental problems. These may include: Bleeding gums when brushing. Broken teeth or fillings. Sensitive teeth. Gum disease (periodontal disease/pyorrhea). Loose teeth. Persistent irritation from dentures. Use a soft toothbrush and fluoride toothpaste. Do not use toothpaste with tartar/whitening control. Brush your teeth and tongue after each meal and at bedtime. Even if you are not eating, brush your teeth to remove the film The dentist will do a complete and bacteria. exam. After brushing your teeth, rinse your mouth with baking soda solution. Mix 1/2 teaspoon baking soda in eight ounces of water. Swish gently and spit. Leukemia patients should ask their nurse for special baking soda rinse instructions. Do not use store-bought mouthwashes. They may contain alcohol or other chemicals that can irritate your mouth. If you floss daily, use waxed floss. If flossing is not one of your routine habits, speak to your doctor before beginning. Do not floss if your platelets are below 50,000(50k/ul).
    [Show full text]
  • Stability Analysis of Carrot-Based Natural Moisturising Lip Balm, Chemical Engineering Transactions, 83, 49-54 DOI:10.3303/CET2183009
    49 A publication of CHEMICAL ENGINEERING TRANSACTIONS VOL. 83, 2021 The Italian Association of Chemical Engineering Online at www.cetjournal.it Guest Editors: Jeng Shiun Lim, Nor Alafiza Yunus, Jiří Jaromír Klemeš Copyright © 20 21 , AIDIC Servizi S.r.l. DOI: 10.3303/CET2183009 ISBN 978-88-95608-81-5; ISSN 2283-9216 Stability Analysis of Carrot-based Natural Moisturising Lip Balm a, a Siti Nuurul Huda Mohammad Azmin *, Nur Solehin Sulaiman , Nurul Aqilah Binti a b a Yosri , Mohd Shukri Mat Nor , Palsan Sannasi Abdullah a Faculty of Agro-Based Industry, Universiti Malaysia Kelantan Jeli Campus, Locked Bag 100, 17600 Jeli Kelantan, Malaysia. b Department of Research and Development, Jeli Agricultural Technology, PT7458 Kampung Gemang Baru, 17700 Ayer Lanas, Jeli Kelantan, Malaysia. [email protected] Moisturising lip balm is an essential cosmetic product to enhance the lips appearance as well as to prevent inflammation or cracked lips. Lip balm with moisturising function formulated using all-natural ingredients is very significant because of the negative side effect awareness among people on using the unnatural or chemically derived ingredients of the lip balm. However, the stability analysis of this natural lip balm must be co nducted to ensure the safety of the product as well as to predict the product shelf life. This study aims to evaluate the stability of carrot lip balm in two weeks under room temperature and refrigerator condition. Three lip balms with different concentration of virgin coconut oil (VCO) to carrot (35:65, 38:62, 43:57) were formulated and tested for their physicochemical properties (texture, colour, pH and spread ability) for two weeks.
    [Show full text]
  • Formulation Development, Testing, and Approval Part I of 2
    Formulation Development, Testing, and Approval Part I of 2 Leon H. Kircik, MD, Joseph B. Bikowski, MD David E. Cohen, MPH, MD Zoe Diana Draelos, MD Adelaide Hebert, MD March 2010 Vehicles Matter elcome to Vehicles Matter, Part I, the first in a two-part series that Table of Contents Wexplores the important role of the vehicle on the efficacy, safety, and tol- erability of a drug formulation. Starting with the process of formulation plan- Topical Drug Delivery . 3 ning through the FDA approval process, this first edition of Vehicles Matter Penetration Enhancers: elucidates the critical considerations that go into designing a new topical Benefits and Challenges. 6 therapy. In Part II (June 2010), we’ll take a closer look at specific drug formula- tions in order to better understand the unique ways that these various prod- Topical Dosage Forms . 8 ucts address the challenges of formulation to ensure tolerability and efficacy. Formulating for Special Populations . 9 The insights you’ll find in this supplement represent the combined knowl- Drug Approval and the edge of a panel of specialists, with expertise in pediatrics, allergic contact der- Case of Corticosteroids . 12 matitis, clinical practice, and research. This seven-member panel convened for a lively and informative dialogue in November 2009. Support for this educational initiative was provided by: I am confident that this innovative and exciting supplement series to Practical Dermatology will help you make more informed therapeutic deci- Allergan, Inc. sions and more effectively communicate those decisions with your patients, Coria Laboratories colleagues, and others involved in patient care. Be sure to visit (A Division of Valeant Pharmaceuticals, NA) VehiclesMatter.com on a regular basis for additional information, a glossary of Ferndale Laboratories important terms, updates on new formulations, and patient education Galderma S.A.
    [Show full text]
  • ECZEMA Tips to Care for Your Skin
    ECZEMA Tips to Care for Your Skin Limit contact with things that can irritate your skin. Some things that may irritate your skin include household cleansers, detergents, aftershave lotions, soap, gasoline, turpentine and other solvents. Try to avoid contact with things that make you break out with eczema. Because soaps and wetness can cause skin irritation, wash your hands only when necessary, especially if you have eczema on your hands. Be sure to dry your hands completely after you wash them. Wear gloves to protect the skin on your hands. Wear vinyl or plastic gloves for work that requires you to have your hands in water. Also, wear gloves when hands will be exposed to anything that can irritate your skin. Wear cotton gloves under plastic gloves to soak up sweat from your hands. Take occasional breaks and remove your gloves to prevent a buildup of perspiration inside your gloves. Wear gloves when you go outside during the winter. Cold air and low humidity can dry your skin, and dryness can make your eczema worse. Wear clothes made of cotton or a cotton blend. Wool and some synthetic fabrics can irritate your skin. Most people with sensitive skin feel better in clothes made of cotton or a cotton blend. Care for your skin in the bath or shower. Bathe only with a mild soap, such as Dove, Basis or Oil of Olay. Use a small amount of soap when bathing. Keep the water temperature cool or warm, not hot. Soaking in the tub for a short time can be good for your skin because the skin’s outer layer can absorb water and become less dry.
    [Show full text]
  • Blue Seal” on Your MOST PEOPLEN0W JUDGE TOOTHPASTE CLAIMS with COMMONSENSE^ Baby to Keep Him 1 1 Well , and Happy
    feel better WHY /S JACOB FAST! SO HAPPY? “K O W IE” UMTWA BRAND 4, Z. S-7 these aches and pains, i Jion of people all over I e world. There are aspirins, but all these m lions of people say ' FOR COLDS, HEADACHES, FEVER, TOOTHACHE, RHEUMATISM Take BAYER ^ASPIRIN T ake your and feel better FAST! This young American medical student PARTONS * REMEMBER THIS RWVMEI to -n ig h t! knows what’s good T ' t f . ALIVE. m^Take^ another She always ately pure, depen brand Petroleum je Seal Jar Dorothy is studyine to he a world-famou Columbia University in Arne is both cleve Petroleum Jelly c BLUE SEAI and soft. No other ‘Vaseline” BLUE and clear. No im burns. Keeps Dor. s AtLoWoA/ hSp trom soreness and * s s s a ? s'3f,=Bssa* V a se lin e *—B L U E S E A L Standard Size 1/6 Petroleum Jellies PARTONS MACLEANS PURIFYING PILLS p e r o x id e TOOTH PASTE Did you MACLEAN your teeth t< Q.C.Z • A.- S -f. | LEA D ER ! three little trnrtls . , „ use m w it/iinffiM tig L Whispered so softly for you alone to hear. Hands § touch . eyes mirror the heart’s emotions . lips meet PEPSODENT Every morning’s a good morning Pepsodent smile—becai when you feel fit and healthy. If For divine moments such as these remember always to you don't, then your system proba­ bly needs the help of sparkling wear the perfume that will make him whisper - “I adore you” Remedy In South Africa t< Andrews.
    [Show full text]
  • Petroleum Jelly Cream Vaselin Enthaltende Creme Creme De Petrolatum
    ~™ mil iiiiii illinium nun (19) J European Patent Office Office europeen des brevets (11) EP 0 716 593 B1 (12) EUROPEAN PATENT SPECIFICATION (45) Date of publicationation and mention (51) |nt. CI.6: A61 K 7/48 of the grant of the patent: 09.12.1998 Bulletin 1998/50 (86) International application number: PCT/EP94/02793 (21) Application number: 94926870.0 (87) International publication number: (22) Date of filing: 23.08.1994 WO 95/06458 (09.03.1995 Gazette 1995/11) (54) PETROLEUM JELLY CREAM VASELIN ENTHALTENDE CREME CREME DE PETROLATUM (84) Designated Contracting States: (72) Inventors: CH DE ES FR GB IT LI NL SE • ROSE, Walter New Haven, CT 06511 (US) (30) Priority: 01.09.1993 US 115490 • ZIMMERMAN, Amy, Christine Ansonia, CT 06401 (US) (43) Date of publication of application: 19.06.1996 Bulletin 1996/25 (74) Representative: Evans, Jacqueline Gail Victoria (73) Proprietors: Unilever pic • UNILEVER PLC Patent Division London EC4P 4BQ (GB) Colworth House Designated Contracting States: Sharnbrook GB Bedford MK44 1 LQ (GB) • UNILEVER N.V. 3013 AL Rotterdam (NL) (56) References cited: Designated Contracting States: EP-A- 0 262 681 EP-A- 0 295 411 CH DE ES FR IT LI NL SE US-A- 3 852 475 CO CO <7> IO CO Note: Within nine months from the publication of the mention of the grant of the European patent, any person may give notice to the European Patent Office of opposition to the European patent granted. Notice of opposition shall be filed in o a written reasoned statement. It shall not be deemed to have been filed until the opposition fee has been paid.
    [Show full text]
  • PED ENT Surgery Post Op and Discharge Plan
    Attach patient label here Physician Orders PEDIATRIC: PED ENT Surgery Post Op and Discharge Plan Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: PED ENT Surgery Post Op Phase, When to Initiate:____________________ Initiate Powerplan Phase Phase: PED ENT Discharge Orders Phase, When to Initiate:____________________ R Powerplan Open PED ENT Surgery Post Op Phase Admission/Transfer/Discharge Return Patient to Room T;N Comments: References and PACU discharge criteria are located on MOLLI. Transfer Pt within current facility T;N Comments: References and PACU discharge criteria are located on MOLLI. Condition Condition Vital Signs Vital Signs Monitor and Record T,P,R,BP, post op Activity Out Of Bed Up Ad Lib Food/Nutrition NPO Clear Liquid Diet Start at: T;N Patient Care Advance Diet As Tolerated start clear liquids and advance to soft diet as tolerated. Daily Weights Routine, qEve Intake and Output q2h(std) IV Discontinue When Tolerating PO IV Discontinue When Bag Complete IV Discontinue Routine, prior to discharge Elevate Head Of Bed 30 degrees Cold Apply Neck, ICE Collar, Routine Dressing Care Routine, Action: Change, PRN, drip pad (DEF)* Routine, Action: Reinforce Only, PRN Trach Care Routine, q-shift Suction Set Up Routine, Yankeur suction at bedside for patient use. Suction Patient PED ENT Surgery Post Op and Discharge Plan 24016 QM0113 PP Rev103018 Page 1 of 5 *111* Attach patient label here Physician Orders PEDIATRIC: PED ENT Surgery Post Op and Discharge Plan q2h(std), PRN, Suction: Nasal (DEF)* q2h(std), PRN, Suction: Oral q2h(std), PRN, Suction: Trach Indwelling Urinary Catheter Care indwelling urinary catheter to gravity Indwelling Urinary Catheter Remove Remove in AM O2 Sat Monitoring NSG O2 Sat Spot Check-NSG T;N, with vital signs Cardiopulmonary Monitor Routine, Monitor Type: CP Monitor Discontinue CP Monitor When ALL Criteria met: No NG-Tube, No PCA, No Chest Tube, No Sepsis Alert notified, PEWS of 0 and 24 hour post op.
    [Show full text]
  • 1. Opt for a Petroleum, Jelly-Based Lip Balm
    Yerin Kim | October 23, 2019 So you have a crush you're dying to kiss, you have your kissing technique down, and you've even brushed up on different types of kisses and kissing positions to up your makeout game. The only thing that's missing to make this the *perfect* kiss? Smooth lips that are ready to be kissed. You might think soft lips aren't that important, but you'd be surprised what a difference they make when you're in the middle of a makeout. Sure, you can probably get away with simply applying a moisturizing lip balm, or a gloss to give your lips that extra shine. But if you're looking to take your makeout to the next level, we're here to help. We asked Dr. Anna Guanche, author and board-certified celebrity dermatologist for her best tips on making your lips look kissable AF. From what kind of lip balm to use to how often you should exfoliate, we're sharing our best- kept secrets (with help from Dr. Guanche) for achieving velvety smooth lips. 1. Opt for a petroleum, jelly-based lip balm There's a reason Vaseline and Aquaphor lip balms never go out of style. Dr. Guanche suggests using simple formulas with petroleum jelly. They add a protective barrier, seal in skin moisture, AND prevent or sooth chapped, cracked lips. 1 2. Or look for balms with beeswax, vitamin E, and tree nut oils If you're not really into petroleum jelly, Dr. Guanche also recommends lip balms with beeswax to soothe your lips, vitamin E for its antioxidant and healing properties, or tree nut oils such as shea butter to provide moisture.
    [Show full text]