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FAST FACTS
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second level
third level
fourth level
fifth level
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Click to edit Master title style=
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 © EPEC Project, 2003
Permission to reproduce for educational purposes granted
Page ‹#›
Module 4:= Pain Management
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Whole Patient Assessment
<= b>FAST FACTS
<= b>Module 3
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice <= /b>
Keyword (s): Caring for families, Communications skills, Death pronouncement, = = Discussing hospice care, Family conference, Giving bad news, Negotiating treatment <= span style=3D'font-family:Arial;font-size:67%;text-shadow:auto;color:yellow'>goals, Personal reflection, Prognosis
Patient-Centered Interviewing: Understanding The Illness Experience
Clinical Case: You admit Mary, a new patient, to the hospital. Mary has end-stage, metastatic pancreatic cancer. <= /span>
She has not seen a physician since she was given a terminal diagnosis 6 months ago at another institution. She is nutritionally depleted and has an apparent gastrointestinal obstructi= on causing significant bloating and discomfort. While you are admitting her she informs you that she is curing herself by drinking fresh fruit and vegetable juices. She refu= ses to discuss advanced directives because she “Does not trust you.”
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How might you begin to develop a working = relationship with Mary?
One strategy is to strive to understand both Mary’s disease and her illness.
Ø Disease refers to a biological, &#= 13;
    pathophysiological process
Ø Illness refers to the patient̵= 7;s experience.
You can assess a patient’s illness experience = by asking about 4 dimensions—
 Feelings, Ideas, Function and Expectations .
The acronym FIFE can be a helpful reminder.
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F =3D FEELINGS= related to the illness, especially fears
What are you most concerned about?
Do you have any specific fears or worries right now?
I imagine you have had many different feelings as you have coped with this illness.
Sometimes people have fears that they keep to themselves and don’t tell their doctor.
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What do you think this pain means?
Do you have ideas about what might have caused this illness?
I =3D IDEAS and explanatio= ns of the cause
What do you think might be= going on?
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How has your illness affected you day to day?
What have you had to give up because of your illness?
What goals do you have now in your life? How has your illness affected your goals?
How does this illness affect important people in your life?
F =3D FUNCTIONING , the illness’ impact on dail= y life
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What do you expect or hope I can do for you today?
 
Do you have expectations about how doctors can help?
What do you hope this treatment will do for you?
What are your expectations about what might happen with this illness?
E =3D EXPECTATIONS of the doctor & the illness
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= References
Ste= wart, M, JB Brown, WW Weston, IR McWhinney, CL McWilliam, TR Fre= eman. Patient Centered Medicine: Transforming the Clinical Method. Sage <= /span>Pub= lications, Thousand Oaks, California, 1995.
Ros= enberg, EE, M Lussier & C Beaudoin. Lessons for clinicians from physician-pat= ient communication literature. Arch Fam Med 1997; 6:279-283
Pla= tt FW and Gaspar DL. “Tell me about yourself”: T= he patient-centered interview. Ann Int Med 2001; 134:1079-= 1085=
Citation for referencing: Fast Facts and Concepts #17 Ambuel, B. Patient centered interviewing. 2nd Edition, August, 200= 5. End-of-Life Palliative Education Resource Center
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice <= /b>
Keyword(s): Negotiating treatment goals
What to do when a patie= nt refuses treatment
A c= ore aspect of the American bioethics is that a competent adult patient has a right to refuse treatment, even when t= he physician believes = that the treatment would be beneficial.
At such a time it is easy to either ques= tion the patient's capacity to make the decision or try even harder to convince them to change their mind.
The empirical literature - both in decision making a= nd in medicine - suggest t= hat this is a false dichotomy and that there is a third more productive way to proceed.
The method described below is applicable= to all situations of conflict bet= ween clinicians and their patients/families.
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Clarify Decisionality
Distinguish between patients who can not understand the medical situation (and thus may lack decision-making capacity) and those who understand your viewpoint bu= t do not agree with it. = ;
Ask, "I have talked with you about the medical problems you are facing and possible treatments for these problems.
Just to make= sure we are on the same page, can you describe = for me the m= edical problems you are dealing with now?"
"Good. = Can you also describe the possible treatments we have discussed?"
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Understand th= eir story
Try to understand the patient/family's story before = you try to change their mind. = ;
This means suspending your attitude towa= rd their decision and as openly and non-judgmentally as possible, understanding <= span style=3D'position:absolute;top:40.75%;left:11.79%;width:84.08%;height:4.5%= '>the reasons for their decision.
This can be done by asking:
  "Tell m= e more about your decision";
  "What leads you to this conclusion?"
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Validate conc= erns
Often when we try to convince others of our position= , we forget to acknowledge the real= ity of their concerns.
This makes them feel unheard and under appreciated. = More effective, are responses which first let the person know they were heard:
 ("so you are concerned that i= f you have surgery you will XX") or that normalize their concerns
 ("it is not that unusual for = people to be afraid of XX")
before you respond to these issues.
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Explore fears=
Fears are stronger motivators than positive induceme= nts. Try to understand your patient/family's fears/concerns with your = plan of action; you can only address their fears if = you understand them. Ask:
 "Can you tell me if there is something about this decision that frightens you".
Establish a w= in-win position
=
If the patient's concern is the lack of control in t= he hospital and your concern is her/his health if s/he leaves the hospital, <= span style=3D'position:absolute;top:74.75%;left:9.36%;width:90.07%;height:4.5%'= >what can you do to provide more control in the hospi= tal?
Negotiate so both of you can achieve what each of you care about the most.
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Ref= erences
 <= /span>Drane, J. F. (1985). "The Many Faces of Competency." Hasting Center Report: 17-19.
 <= /span>Stone, D., Patton, B. et al. (1999). Difficult conversations: How to Discuss What matters Most. New York City, Penguin Group. Appelbaum, P. S., Roth = and L. H. (1983). "Patients who refuse treatment in Medical hospitals." JAMA 250: 1296-13= 01.
Citation for referencing. Fast Facts and Concepts # 56 . Arnold R.What to do When a Patient Refuses Treatment. November, 2001. End-of-Life Physician Education Resource Center
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice <= /b>
Keyword(s):  Communications skills, Death pronouncement, Discussing hospice care, = Family conference, Giving bad news, Negotiating treatment goals, Personal reflect= ion, Prognosis
Responding to Patient Emotions
Listening to, recognizing, and responding to patient emotions is an essential skill for physicians who care for dying patients.
We often think of this skill as innate — either we have the skill as an attribute of our personality, or we don’t. In fact the skill of responding empathetically to patient emotions can be learned.
Here are eight tasks that guide you in responding to patient emotion
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Listen: <= /b>
Do not interrupt while the patient is talking.
Patients and families facing end-of-life decisions want an opportunity to talk with their doctor about what they are thinking and feeling.
Listen to the Patient.
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Be aware of your own emotions.
Your feelings of sadness, anger, anxiety, fear or happiness are often= the first clue that a patient is communicating an important emotional message.
Avoid the trap of quickly acting on your emotions.&#= 13;
For example, if you find yourself feeling angry,
do not tell the patient you are angry:
instead use your feeling of anger as a cue to
find out more about what the patient is saying.
Listen to yourself
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Reflection means re-stating what a patient has said using their own words and phrases.
Reflection
1) tells the patient that you are listening and care, =    giving permission to d= iscuss sensitive topics;
 2) allows the patient to listen to= their own
    thoughts, heightening= their self-awareness;
 3) allows the patient to confirm, correct or amplify      upon your understanding.
Reflect thoughts, feelings and behavior
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Example #1: Reflecting thoughts:
= Patient: “This is a tough decision…I just can’t decide whether I want to enter a hospice program or continue with chemotherapy.”
= Physician: “You are having a hard time deciding between hospice and chemotherapy.”
Affirmation & respect.= Patients and families take a risk when they = share their emotions; affirm and support the patient.&#= 13;= Examples: Thank you for shari= ng your feelings and thoughts. or, I’m glad that= you are talking with me about your feeling. or, I can do a better job as your doctor when I know how you are feeling.
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Example #2: Reflecting emotions:
 
Patient: “I’ve been feeling run down and discouraged. I guess I’m a little overwhelmed.”
 
Physician: “You have been feeling discouraged and overwhelmed …”
Empathic curiosity. Be curious and request more information: <= /b>I’d l= ike to know more about this…; or Please tell me more about the sadness you are feeling ….
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Example #3: Reflecting behavior:
=
Patient begins to cry.
Physician: “I see that you are crying…”
•<= /span>Make a plan.<= /b> Sometimes a patient simply wants to talk about their feelings; other times, action may be important.
•Possible action s= teps include making changes in how you and the patient communicate, helping the patient ident= ify sources of social support, and changing the plan= of care.
•Find out what the patient is expecting—How can I help? or, What, if anything, w= ould make a difference for you?<= /i>
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References
Egener, B. (1997) Empathy. Behavioral medicine in primary care: a pra= ctical guide. M.D. Feldman and J.F. Christensen. Stamford, Connecticut, Appleton & Lange: 8-14.
Cole, S & Bird, J. (2000). The Medic= al Interview: The Three Function App= roach. Second Edition. St. Louis, Missouri, Mosby.
Cit= ation for referencing: Fast Facts and Concepts #29. Ambuel, B. Responding to pat= ient emotion. August 2005, 2= nd edition. End-of-Life Physician Education Resource Center=
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice <= /b>
Keyword(s): Communications skills, Death pronouncement, Discussing hospice care, <= /span>= Family conference, Giving bad news, Negotiating treatment goals, Personal reflect= ion, Prognosis, Spirituality
Taking a Spiritual History<= /b>
Illness raises fundamental questions –
For what may I hope? Why do I suffer? Does my suffering have = meaning? What happens after I die?
When a physician stands with a patient as they face death, the physician inevitably plays a role in supporting the patient’s inquiry into = these spiritual questions.
In addition some patients have specific preferences = or needs regarding medical c= are, death and dying that are based upon their religious = beliefs. The physician often plays an important role in supporting a patient’s explorati= on of these issues. Taking a spiritual history is one way to support the patient in this exploration. =
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S—spiritual belief system
Do you have a formal religious affiliation? Can you describe this?
<= /span>
Do you have a spirit= ual life that is important to you?
<= /span>
What is your clearest sense of the meaning of your life at <= span style=3D'position:absolute;top:52.75%;left:14.41%;width:76.02%;height:5.25= %'>this time?
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P—personal spirituality
=
Descri= be the beliefs and practices of your religion that you = personally accept.
<= /span>
Describe those beliefs and practices that you do not accept or = follow.
<= /span>
In what ways is your spirituality/religion meaningful for you?
<= /span>
How is your spirituality/religion important to you in daily life?
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I—integration with a spiritual community
Do you belong to any religious or spiritual groups or communities? &#= 13;
<= /span>
How do you participa= te in this group/community?
What is your role? &= #13;
<= /span>
What importance does this group have for you?
<= /span>
In what ways is this group a source of support for you?
<= /span>
What t= ypes of support and help does or could this group provide for you in dealing with health issues?
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R—ritualized practices and restrictions
What specific practi= ces do you carry out as part of your religious= and spiritual life (e.g. prayer, meditation, service, etc.)
What lifestyle activities or practices does your religion encourage, discourage or forbid?
What meaning do these practices and restrictions have for you? To what extent have you followed these guidelin= es?
&= #13;
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I—implications for medical care
Are th= ere specific elements of medical care that your religion discourages or forbids?
To what extent have = you followed these guidelines?
<= /span>
What aspects of your religion/spirituality would you like to keep = in mind as I care for you?
<= /span>
What knowledge or understanding would strengthen our relationship as physician and patient?
<= /span>
Are there barrie= rs to our relationship based upon religious or spiritual issues?
<= /span>
Would you like to discuss religious or spiritual implications of = health care? &#= 13;
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T—terminal events planning
<= /div>
Are th= ere particular aspects of medical care that you wish to forgo or have withheld because of your religion/spirituality?
 
Are th= ere religious or spiritual practices or rituals that you would like to have available in the hospital or at home? <= /i>
<= /span>
Are th= ere religious or spiritual practices that you wish to plan for at the = time of death, or following death? <= /span>
<= /span>
From w= hat sources do you draw strength in order to cope with this illness?
<= /span>
For what in your lif= e do you still feel gratitude even though ill?
<= /span>
When you are afraid = or in pain, how do you find comfort?
<= /span>
As we = plan for your medical care near the end of life, in what ways will your religion and spirituality influence your decisions?
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References:
Maugans TA. The SPIRITual History. Arch Fam Med. 5:11-1= 6, 1997.
Ambuel, B & DE Weissman. Discussing spiritual issues and maintaining hope. In DE Weissman & B Ambuel, Improving End-of-Life Care: A Resource Guide for Physician Education, 2 nd Edition. Medical College of Wisconsin, Milwaukee, 1999. <= /span>
Griffith, JL & ME Griffith. Hope in suffering/pain = in health: Talking with patients about spirit= ual issues. Presented at The Eighteenth Forum for the Behavioral = Sciences in Family Medicine, Chicago, Illinois, October, 1997.
Citation = for referencing. Fast Facts and Concepts #19 Ambuel B. Taking a spiritual = history. August 2005. 2nd Edition. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.
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g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } }function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames= Mode() ) || (event && event.keyCode=3D=3D32) ) { =09 if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex= t ) return; parent.GoToNextSld(); } } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D30, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0056.htm",1,-1,1),new hrefList(= "slide0169.htm",1,-1,1),new hrefList("slide0170.htm",1,-1,1),new hrefList("= slide0196.htm",1,-1,1),new hrefList("slide0171.htm",1,-1,1),new hrefList("s= lide0172.htm",1,-1,1),new hrefList("slide0173.htm",1,-1,1),new hrefList("sl= ide0174.htm",1,-1,1),new hrefList("slide0175.htm",1,-1,1),new hrefList("sli= de0176.htm",1,-1,1),new hrefList("slide0177.htm",1,-1,1),new hrefList("slid= e0178.htm",1,-1,1),new hrefList("slide0179.htm",1,-1,1),new hrefList("slide= 0180.htm",1,-1,1),new hrefList("slide0181.htm",1,-1,1),new hrefList("slide0= 182.htm",1,-1,1),new hrefList("slide0197.htm",1,-1,1),new hrefList("slide01= 98.htm",1,-1,1),new hrefList("slide0183.htm",1,-1,1),new hrefList("slide018= 4.htm",1,-1,1),new hrefList("slide0185.htm",1,-1,1),new hrefList("slide0186= .htm",1,-1,1),new hrefList("slide0187.htm",1,-1,1),new hrefList("slide0188.= htm",1,-1,1),new hrefList("slide0189.htm",1,-1,1),new hrefList("slide0190.h= tm",1,-1,1),new hrefList("slide0191.htm",1,-1,1),new hrefList("slide0192.ht= m",1,-1,1),new hrefList("slide0193.htm",1,-1,1),new hrefList("slide0195.htm= ",1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01C7D457.13AE45E0 Content-Location: file:///C:/4E921AF3/Module3WholePatientAssessment_FastFacts_files/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" ------=_NextPart_01C7D457.13AE45E0 Content-Location: file:///C:/4E921AF3/Module3WholePatientAssessment_FastFacts_files/buttons.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhWAESAPf4AAAAAIAAAACAAICAAAAAgIAAgACAgICAgAQEBISEBASEBISEhAQEhMTExAQE /KTM9Pz8/ERERPz8BAT8/KSkpGRkhMTcxCRkxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAMDAwP8AAAD/AP//AAAA//8A/wD//////yH5BAEAAPgALAAAAABYARIA QAj/APEJHEiwoMGDCBMqXMiwocOHECNKnEixosWLGCEiQKCRo8YDIEHig2DxAD4LKD1avDDhgUuV GUOGbHBR5QGYFBG4fHAB58EKECJEwCfUYAWPFGAygLCRKQIIUKM6WAohKUGgCikcFWh1INWoYKVS 7SrQ41GbIhGYLAuVQVOoC+IyXUuUAkG1HE3KFDhAwkgJc5/qDZmxsOHDiBMrXsy4sePDGyP7lChT 5MULmDPnlDw5YmW6FTNrfgi0aNGEZPEtbfo2bNTUpYeeRph69dPWrqvCNFuBIGG1A59CYPAVQtwF cw0OxWdTIOiBCQAjaAB17fOFII8voGmRc+eOkilm/z9OvTtnjN4hYk1YoT3H2rnBOphPAB9skgq3 2lcaX/5YnJVt9BloAar12UEIRGCZdQghMABI1Tn32IQUVthYexhmqGGGMBHAgIfEhSiiiATAtOGJ GnYI4ogsEldicAYOGNJGZaml3Y0L3NTZUBz1xlB0PUoUI0jlVWRSVN89xBKSGB1YU1TMoRfVBEle hR9HQs1GEHxQ3RZZbveZthxt/LEmXHyp5XWABSCpaRJwbM13gAACPHVccgJFgF+NEhqUAEkQSCfc ddhVhh5dVTaEAEsTUNlkZUWKN9BNGDE6QU8OrSdbllzpxyVTTrU21Uj3scfhp7nNpyoDaTIEJ3P9 If8J2kbLNYegg9JRBwGhFvbq66+ZUiDssMQWK2yHxiZLrInKNotss8l+B5yBrr5p2UIJvortANoC 6+234IbLla/elRtZjeamh5CC3Sb0YLvixivvYkDFGlZqBNh7r4n6goVvv6/ZlCicN+kL71ALTnpQ dCIZp7CihkLA3UQmoWRBogyxtBPGCTnZncVR1rSTo5nuydC/Eo8kUH+lOoTyyvjoCuZu+PjYIKLD rZybtrM1d10C0QXKEVz48GrQkEeWdFJKlbb0UmEeV0SzyC6RvNB646LWIVjUNeC1zAFb+RDKXksM 9r531bwmpQW9+hQDDsx5pqwDRWBXcFES2hc+gEn/wJGdEEWdE6LoWcoxQweaTNmkhydkKaYMYY2Q p1unbLl/pPKbn3v7EZRvrKvqlja2ONvrtoIw9tn2g32/tQBlhtYkU+MNikZ7QYlPDPuMldpOmuJX nVo5VF3HjI+q89mteX5IDd/fVFClma5kiE4f2XUJhlz09gj2NbTDRifkmu7zXjR++RVJ/lPznuvr QH2iD6S+UewP9Dnon6d2NLwN8n90BB6hC68cFMCHoe+ACASP9c4DowUyEF0OPFcDI0ij/VXPaAKC UfhS95AKGoQ7IBRICI1HwhGaUIQoLGEKT6jCFrLwhSuMoQtlCMMZ2rCGOKShDm+4wxzy8Ic+DGIP B4cIRCKGMCAAOy== ------=_NextPart_01C7D457.13AE45E0 Content-Location: file:///C:/4E921AF3/Module3WholePatientAssessment_FastFacts_files/frame.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4 ------=_NextPart_01C7D457.13AE45E0 Content-Location: file:///C:/4E921AF3/Module3WholePatientAssessment_FastFacts_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
 No= tes
Slide Show
Outline
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