Theoretical knowledge of clinical pharmacy

1. Pharmaceutical Care
Mohammed A
B.pharm, M.clinpharm
Clinical pharmacist
27/10/2013 Mohammed A 1

2. Overview of Clinical Pharmacy…
• All patients have drug-related needs, and it is the PC practitioner's
responsibility to determine whether or not a patient's drug-related needs are
being met.
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3. The Pharmaceutical Care Cycle
• In PC practice, talking with the patient is a vital component to uncovering more and
different drug therapy problems
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4. Do we still need pharmacists? Ask yourself
Case-I
• A nine-month old baby died after misplaced decimal causes 10-
fold morphine overdose
• Physician ordered Morphine .5 mg IV for post-op pain, unit
secretary does not see the decimal and transcribes the order as
Morphine 5 mg IV
• Experienced nurse administered 5 mg of Morphine and repeats the
dose 2 hours later
• Four hours later baby stops breathing
Washington Post, April 20, 2001
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5. Case-II
• 44 y/o F in died in an emergency department after
receiving 8,000 mg IV phenytoin instead of 800 mg
• A nurse administered overdose
– 32 vials of 50 mg / mL, 5 mL
– Required removing medication from several automated
dispensing machines
ISMP Medication Safety Alert, March 8, 2007
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6. Case-III
An elderly woman from Harar died after she received IV
injection of potassium phosphate that was supposed to be
administered via a feeding tube.
ISMP Medication Safety Alert, March 8, 2007
Case-IV
• An intern doctor in a hospital in Addis writes a script for 20 vials
of heparin for a patient admitted to the ER for DVT
Case-V
• A women with unadjusted dose of anti Tb meds at a CrCl of 7.5
JUSH 2012.
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7. Why pharmacist??
• Pharmacies are open all the time.
• No need for an appointment to see the pharmacist.
• Accessible and trusted source of advice
• Convenient for most people
• First stop for help with common ailments.
• Have the expertise to advise both on the choice of
medicines and their safe and effective use.
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8. What is wrong with the “old model?
(Physicians Prescribe and Pharmacists Dispense)
• Healthcare costs
– Medicine related errors are costly in terms of hospitalizations, physician
visits, laboratory tests and remedial therapy
• Adverse drug reaction:
– 4%-10% of all hospital in-patients in developed countries.
– The 4th-6th leading cause of death in USA
– Estimated cost: upto US $ 139 billion a year in the USA
– £ 466 million (over $812 million): in the UK
‘’No documented data in our country’’
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9. What is Wrong with the Current/old System?
Cont…
More than 50% of all prescriptions are incorrect
50%–90% of medicines purchased are paid for out-of-
pocket in developing countries.
non compliance is a major issue.
 >50% of the people involved fail to take
them correctly.
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10. What is Wrong with the Current/old System?
Cont…
• Up to 90% developed resistance to original first-line antibiotics
such as ampicillin and cotrimoxazole for shigellosis,
• Up to 70% resistance to penicillin for pneumonia and bacterial
meningitis,
• Up to 98% resistance to penicillin for gonorrhea, and
• Up to 70% resistance to both penicillin and cephalosporin for
hospital-acquired S.aureus infections.
‘’ no documented data in Ethiopia’’
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11. What is Wrong with the Current/old System?
Cont…
Inadequate of Accountability?????
If a patient died after taking a prescription drug that
was dispensed according to the physician order
correctly, who is responsible?
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12. What is Wrong with the Current/old System?
Cont…
The old
“Physicians Prescribe and Pharmacists Dispense” model
is no longer fully appropriate to
 reduce drug therapy problems,
ensure safety,
ensure effectiveness and
adherence to drug therapy.
What could be a solution?????
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13. Role change
• Sweeping changes continue to reshape the practice of
pharmacy.
• The pharmacy professional needed today is a
knowledgeable drug expert and skilled, persuasive
communicator and not a pill counter.
This pharmacist embraces a new
practice model - pharmacy care.
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14. Global shift in the Practice of Pharmacy
• US and Iran: early 1960s: Pharm D
• US: 2000 Pharm.D mandatory for Pharmacy Schools
Other continents:
• Asia: India: Pharm.D: 2007
• Africa: Egypt: Alexandria University
• South Africa, Zambia: baccalaureate degree + internship in clinical areas
• UK, Australia, malasyia, KSA, Jordan,palastine:
M.clinpharm (MSc Clinical Pharmacy)
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14

15. Why in Ethiopia?
• Ethiopia is one of the countries in the world with a critical
shortage of health workers and not to fully utilize its trained
workforce
• in a better position to have the expertise to advise both on the
choice of medicines and their safe and effective use.
• Major issues with medication access, quality, and rational use
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16. Why Now?
• HIV/AIDS is a major burden in developing countries
– 40 million people death because of HIV/AIDS
– Close to 3 million annually
• Life style is becoming westernized DM, HTN, HF, CKD, chronic
illnesses. New meds are being imported to Ethiop
 demand to meds expert is clear
• Though critical shortage of HC professionals but the existing
should be utilized to their fullest capacity including pharmacists
• Existing skills should be upgraded to cope up with demand
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17. Pharmaceutical Care in Ethiopia
• Curricular revision 2008: nationwide
• Pharmacy curriculum: more patient oriented (4 years + 1
internship)
• FMoH: EHRIG May 2010
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18. 27/10/2013 Mohammed A 18
PC in Ethiopia

19. Definition
“Pharmaceutical care is the responsible provision of drug therapy
for the purpose of achieving definite outcomes that improve or
maintain patient’s quality of life” (Hepler and Strand, 1990) & 1999 FIP
preventing a disease or Sx
elimination or reduction of a patients Sx
arresting or slowing of a disease process
cure of a disease
19
Mohammed A
27/10/2013

20. Background
• In the last 4 decades the trend in the pharmacy practice moved
from medicine supply  more inclusive patient care
• Pharmacists role evolved from compounder, supplier of
pharmaceuticals a provider of services, info & patient care.
• Pharmacists tasks is to ensure
pts drug therapy is appropriately indicated
the most effective available
Safest possible and convenient for the pt
Unique contribution for : DT outcome and pts Quality of life
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21. Background...
• The literature provides powerful evidence of need for
pharmacist to change.
Crisis in health care funding,
cost of Rx,
need to add value to basic commodities like Rx.
• A pharmacist who is unable or unwilling to adapt to a new
role places millions/billions of money at loss.
21
Mohammed A
27/10/2013

22. Background...
• ‘Pharmacy’ believes clinically and financially in increased patient
care, but pharmacists have not fully adopted a new practice
philosophy.
• Probably a combination of inadequate
Knowledge (easy to fix)
Skill (easy to fix)
Attitude (hard to fix)
• PC is not the current standard of practice. What you see at work
rarely reflects what you hear in class
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Mohammed A
27/10/2013

23. Background...
• Consider what you have seen in almost all pharmacies so far in our
country.
Meds without prescriptions, inadequate counseling, lack monitoring, missing of DDI checker
• Most problems are discovered only when a pharmacist thinks
“that can’t be right! or when the computer goes beep, beep, beep!
• Did the pharmacist find the problem or did the problem find the
pharmacist?
‘’not safe to assume the practice we see today is the same practice w/c will
be few yrs from now’’ hope vs hard work?????
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Mohammed A
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24. Background...
• Expert knowledge of therapeutics
• A good understanding of disease process
• Knowledge of pharmaceutical products
• Drug monitoring skills
• Provision of drug information
• Communication skills
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Mohammed A
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25. Pharmaceutical Care - Benefits
• Decrease medication misadventures
• Increase patient compliance to therapy
– Empowers patients to take in-charge of their own health and treatment
• Decrease healthcare cost and demand
• Decrease morbidity of mortality
• Increase patients’ quality of life
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26. Goal of Pharmacists
Clinical Training
• To make them experts in:
– identifing and solving medication therapy problems
– becoming patient educators
– selecting the most effective therapy
– monitoring the outcome of drug therapy
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Mohammed A
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27. What is the Focus of the
New Pharmacy Curriculum?
• Clinical Application of Drug Therapy
• Treatment guideline, Disease state knowledge
• Diagnostic procedures (to identify a drug problem)
• Monitoring parameters (lab, physical exam, other diagnostic tools) to
follow efficacy and safety of drug therapy.
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Mohammed A
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28. Change in Pharmacy Education
• Are we behind by 20 years from the rest of the world?
• Pharmacists may be expert in medicinal chemistry and
pharmaceutics – but is this enough?
• Need the knowledge to apply to patient care (direct patient care
involvement)
• Pharmacy education around the world has made a shift
– From lab-based to practical or clinical based.
– From technical aspect to professional aspect of pharmacy 28
Mohammed A
27/10/2013

29. The Pharmaceutical Care Cycle
• In pharmaceutical care practice, talking with the patient is a vital component to
uncovering more and different drug therapy problems
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30. PC Cycle…
• A pharmacist practices PC when he/she finds and fixes or prevents
drug therapy problems in patients.
Medical problems
• A disease state ; A change in physiology that (potentially) results in clinical
evidence of damage to an organ system. E.g. HTN, HF, DM, etc.
Drug therapy problems
• A patient problem that is either caused by a drug or may be
treated/prevented by a drug
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31. Comparing Problems and Treatments
• The pharmacist needs to answer the following
questions:
1. Are all conditions being managed?
2. Are all drug therapies managing a condition?
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32. Medical Vs drug therapy problems
• So, how does this differ from a medical problem?
• Who in the health care system finds and fixes medical
problems?
• Who in the health care system finds and fixes drug
therapy problems?
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33. Drug Therapy Problem
• A drug therapy problem is any undesirable event experienced by
a patient which involves, or is suspected to involve, drug therapy,
and that interferes with achieving the desired goals of therapy.,
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34. Components of a Drug Therapy Problem
1. An undesirable event or risk of an event experienced by the patient.
{medical complaint, S/S, Dx, d/ses, illness, impairment, disability, abnormal
laboratory value, or syndrome. The event can be the result of physiological,
psychological, sociocultural, or economic conditions.}
 The problem
1. The drug therapy (products and/or dosage regimen) involved.
2. The relationship (exists or is suspected to exist) b/n the undesirable
patient event and drug therapy.
• the consequence of drug therapy, suggesting a direct association or even a cause and effect
relationship, or
• to require the addition or modification of drug therapy for its resolution or prevention.
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35. Drug Therapy Problems
1. The drug therapy is unnecessary because the patient does not have a
clinical indication at this time.
2. Additional drug therapy is required to treat or prevent a medical
condition in the patient.
3. The drug product is not being effective at producing the desired response
in the patient.
4. The dosage is too low to produce the desired response in the patient.
5. The drug is causing an adverse reaction in the patient.
6. The dosage is too high, resulting in undesirable effects experienced by
the patient.
7. The patient is not able or willing to take the drug therapy as intended.
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36. Drug-Related Needs of Patients
1. Patients need every medication they are taking to have an
appropriate indication.
• If a drug does not have an appropriate indication, the drug therapy problem “unnecessary
drug therapy” will be identified.
2. Patients need their drug therapy to be effective
• When a patient’s need for medication to be effective is not met, two possible drug
therapy problems can arise. They are “wrong drug” and “dosage too low”.
3. Patients need their drug therapy to be safe
• Not meeting a need for medication safety can result in the drug therapy problems of
“dosage too high” or “adverse drug reaction.”
4. Patients need to be able to comply with drug therapy and
other aspects of their care plans
• Not meeting a need for medication safety can result in the drug therapy
problem of “noncompliance” results.
5. Patients need to receive all drug therapies necessary to resolve
any untreated indications.
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37. Drug-related needs Categories of drug therapy
problems
INDICATION 1. Unnecessary drug
therapy
2. Needs additional drug
therapy
EFFECTIVENESS 3. Ineffective drug
4. Dosage too low
SAFETY 5. Adverse drug reaction
6. Dosage too high
COMPLIANCE 7. Noncompliance
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38. Identifying Drug Therapy Problems
• A pharmaceutical care practitioner should have a tacit
understanding of the common causes of drug therapy problems
identification is the essence of PC practice.
• the practitioner & patient can rationally construct a care plan to
resolve that DT-problem the patient to achieve his/her goals
of therapy.
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39. Identifying DTP…
• These problems are identified during the assessment process, so
that they can be resolved through individualized changes in the
patient's drug therapy regimens.
Sociological, pathophysiological,
knowledge (pt, d/se), identified in the assessment step
drug therapy information
• The synthesis and application of this knowledge occurs in a
logical, systematic manner using the Pharmacotherapy Workup.
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40. Identifying DTP…
The Process Used to Identify Whether or Not the Patient Is Experiencing a Drug
Therapy Problem Requires a Continuous Assessment of Four Logical
Questions:
1. Does the patient have an indication for each of his/her drug therapies, and is
each of the patient's indications being treated with drug therapy?
2. Are these drug therapies effective for his/her medical condition?
3. Are the drug therapies as safe as possible?
4. Is the patient able and willing to comply with the drug therapies as
instructed?
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41. Common Causes of Drug Therapy
Problems
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42. 1. Unnecessary drug therapy
• no valid medical indication. problem
• duplication of therapy
• nondrug therapy more appropriate
• Treating an avoidable ADR.
• Addiction/recreational use
Appropriate indication = Need
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Causes

43. 2. Need for additional drug therapy
• condition requires initiation of DT.
• Preventive/prophylactic DT is required
• additional DT for synergistic/additive effects.
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Causes

44. Minicase 1
• you are the pharmacy intern on community pharmacy rotations at Hiwot
Fana hospital Pharmacy and Mrs.Tigist comes in to ask you to
recommend an OTC sleep aid. In your conversation with her, you learn
her husband has recently passed away and she is not coping well. You
believe she is probably depressed and feel you should probably call her
physician.
• What is her drug related need?
• What is her drug therapy problem?
• How do you contact her physician and not appear to be“practicing medicine”?
DTP occur when one or more of a patient s needs for drug therapy are not met.
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45. Clinical Questions to consider
• Is there an untreated indication? Why?
• Does the patient need synergistic therapy to supplement
therapy already being administered?
• Does the patient need prophylactic therapy?
• Does each medication the patient is taking correlate with a
medical condition?
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46. 3. Ineffective drug
• Contraindications present. BB for class-IV CHF
• The medical condition is refractory to the drug
product.
• The dosage form of the drug product is inappropriate.
PO meds for comatose pts
• More effective drug is available.
Amilodipine for nephrotic syndrome. Verapamil, ACEIs
• not an indicated drug for the condition.
Anbt for URTI, ACEI/BB for hypertensive pregnant women
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Mohammed A
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47. 4. Dosage too low
• The dose is too low to produce the desired response.
Wrong dose. insulin
• The dosage interval is too infrequent to produce the desired
response. Frequency inappropriate
• The duration of drug therapy is too short to produce the desired
response. Penicillins 2 14 days for L.monocytogens
• A drug interaction reduces the amount of active drug available.
Warfarin + phenobarb
• Incorrect storage
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48. 5. Dosage too high
• Dose is too high
• The dose administered too rapidly Wrong dose
• The dosing frequency is too short
• The duration of drug therapy is too long.
Antibiotics for several months . JUSH
• A drug interaction occurs resulting in a toxic reaction to the drug
product. Warfarin + clarithromycin
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49. Clinical Questions to consider
• Are the dose, dosage interval, duration of therapy, and
dosage form appropriate for each medication the
patient is taking?
• How long has the patient been receiving the current
dose of each medication?
• Is the patient responding appropriately to the drug?
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50. 6. Adverse drug reaction
• The drug is Unsafe for the patient.
Amg for CKD, ACEIs for ARF, floroqiunolones and TTC in children
• A drug interaction causes an undesirable reaction that is not dose-related.
• dose inc/dec too rapidly.
• Incorrect administration of the drug. extravasations with Chemos
• The drug causes allergic reactions.
• Undesirable effect.
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51. Questions
• Is there evidence of adverse effects or drug allergies?
• Are the medications being stored properly and are any past
their expiration dates?
• Are medications being administered correctly?
• Are there any potential or actual drug interactions?
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52. 7. Inappropriate compliance
• The patient does not understand the instructions.
• The patient prefers not to take the medication.
• The patient forgets to take the medication.
• The patient cannot swallow or take appropriately. clindamycin
• The drug is too expensive for the patient. vancomycin
• The drug is not available for the patient. psychiatry, cardiac, statins
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53. Questions
• Is the patient misusing medication, whether
unintentionally or deliberately?
• Would nondrug therapy be preferable for any of the
patient’s conditions?
• Is the patient taking duplicate therapy without adequate
cause?
• Are any drugs being administered unnecessarily to treat
adverse effects
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54. Most common medical diseases/conditions associated
with drug therapy problem
• Over age 65
• DM
• Arthritis
• Depression
• Hypertension
• Asthma
• Anxiety
• Hyperlipdemia
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55. Discovering Drug Therapy Problems requires more
than chart review
Example
• KT, a 67-year-old man admitted with a probable thrombotic stroke. The patient
was on warfarin 1 mg tablet for atrial fibrillation, esomeprazole 20 mg for
gastric reflux, and an albuterol inhaler for occasional mild asthma.
• In talking with the patient, the pharmacist found that KT was not taking his
warfarin because he runs out. His stroke and hospitalization are a direct result
of the drug therapy problem of noncompliance.
• The pharmacist uncover the drug therapy problem by discussing with the
patient
• The pharmacist would not be able to get this if he only relies on the patient
chart.
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56. Mini-cases
which patient need is not met, what is the most likely drug therapy
problem, and what is the cause of the drug therapy problem?
Case-1: A woman who is 6 weeks pregnant presents a new
prescription for atorvastatin 20 mg daily written by a cardiologist
who she saw for the first time.
Case-2: A patient with Parkinson’s’ Disease has tremor that make it
nearly impossible to administer his glaucoma eye drops.
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57. Mini-cases…
• Case-3: A child with chronic, persistent asthma is being treated
with nebulized albuterol treatments four times daily.
Case-4: An obese patient with blood pressure controlled by
felodipine starts the “grapefruit juice” diet.
Case-5: A patient who travels for work keeps his insulin in the car’s
glove compartment.
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58. Steps in the Pharmaceutical Care Process
1. Developing a profession relationship with the patient
2. Collecting patient-specific medical information
3. Evaluate patient-specific medical information and develop a drug
therapy plan mutually with the patient.
4. Ensure the patient has all supplies, information, and knowledge
necessary to carry out the drug therapy plan.
5. Review, monitor, and modify the therapeutic plan as necessary and
appropriate, in concert with the patient and health care team.
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59. Actual and Potential Drug Therapy Problem
a. An actual problem
– Is one that has already occurred. Action should be taken to resolve it.
– The best you can do is treat them
b. A potential problem
 Is one that is likely to occur.
Potential problems have not occurred.
They can be prevented. The necessary steps should be taken prevent it
Prevention is a HOT topic and a great professional opportunity!
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60. Actual and Potential DTP…
Case-1:
While working at Jogla Hospital out patient Pharmacy during
your internship, you accidentally fill an Rx for penicillin for
Bilal Adil who is allergic to penicillin.
a) Before you can call him he takes the penicillin. He claims he’s fine
when you reach him by phone that evening.
b) Before you can call him he takes the penicillin. When you reach his
home his neighbor tells you he he’s in the s emergency room!! !!
What type is the DRP ??
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61. Actual and Potential DTP…
Case-2:
• A patient requests a new albuterol inhaler every two or three
weeks. The pharmacist determines his inhalation technique is
adequate but the patient complains of frequent shortness of
breath.
• Case-2:
• A woman who is 6 weeks pregnant has just been diagnosed with
atrial fibrillation and presents a new prescription for wafarin 5 mg
daily written by a cardiologist who she saw for the first time.
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62. Actual and Potential DTP… (Communications tips)
Communications tips
• Docs do not care about drug therapy problems. They care about
patients with problems.
NB: Wording is critical to success - “Dr, I think I have
discovered the drug therapy problem of WRONG DRUG in your
patient!!!”
Re-phrase them ALL as patient problems
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63. Actual and Potential DTP… (Communications tips)
Mini-case:
While you were on your ambulatory care rotations, A resident Dr started
amlodipine10mg po qd for a patient with BP of 164/102. This patient has never
had it before. You think this is too high a dose (usual initial dose is 2.5-5mg qd)
How do you re-phrase the “dose too high” problem in words that will not offend
the Doctor.
i.e. what’s the patient problem?
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64. SOAP Notes
PC practitioners collect two types of data to help them evaluate and
mange patients’ drug therapy:
Subjective data
– Cannot be directly measured
– May not always be accurate or reproducible
– Often supplied directly by the patient
– Generally includes PMH, CC, HPI, SH, FH
the pharmacist collects directly from patients
NB: Only information pertinent to specific drug therapy should be included
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65. SOAP Notes…
Objective data
• Can be measured and observable
• Not influenced by prejudice or emotion
• Typically numerical
• Often includes vital signs, lab measures
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66. SOAP Notes…
Chief complaint (C/C)
Brief statement of the reason why the patient consulted the
physician, stated in the patient’s own words. In order to convey
the patient’s symptoms accurately, medical terms and diagnoses
are generally used.
“What is your main health related problem
today? Health-today?”
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67. SOAP Notes…
History of Present Illness (HPI, HOPI)
• A more complete description of the patient’s symptom(s). Usually
included in the HPI are:
– Date of onset
– Precise location
– Nature of onset, severity, and duration
– Presence of exacerbations and remissions
– Effect of any treatment given
– Relationship to other symptoms, bodily functions, or activities (e.g.,
activity, meals)
– Degree of interference with daily activities
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68. SOAP Notes…
Past Medical History (PMH)
– PMH includes serious illnesses, surgical procedures, and injuries the patient
has experienced previously. Minor complaints (e.g., influenza, colds) are
usually omitted.
Family History (FH)
– FH includes the age, and health of parents, siblings, and children.
– For deceased relatives, the age and cause of death are recorded
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69. SOAP Notes…
Social History (SH)
• SH includes the social characteristics of the patient as well as the
environmental factors and behaviors that may contribute to the
development of disease.
Medications (Meds)
• The medication history should include an accurate record of the
patient’s current prescription and non-prescription medication use.
Allergies (All)
• Allergies to drugs, food, pets, and environmental factors (e.g., grass,
dust, pollen) are recorded.
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70. SOAP Notes…
Review of Symptoms (ROS)
• In ROS the examiner questions the patient about the presence of
symptoms related to each body system.
• In many cases, only the pertinent positive and negative findings
are recorded.
• In a complete ROS, body systems are generally listed starting from
the head and working toward the feet and may include:
the skin, head, eyes, ears, nose, mouth and
throat, neck, cardiovascular, respiratory, gastrointestinal, genitourinary,
endocrine, musculoskeletal, and neuropsychiatric systems.
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71. SOAP Notes ROS …
Physical Examination (PE)
• The exact procedures performed during the physical examination
vary depending upon the chief complaint (C/C) and the patient’s
medical history.
The general sections of PE are outlined as follows:
– GA (general appearance)
– VS (vital signs)-blood pressure (BP), pulse(PR), respiratory rate (RR),
temperature (T)
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72. SOAP Notes ROS …
• HEENT (head, eyes,ears, nose, and throat)
• Lungs/Thorax (pulmonary)
• Cor or CV (cardiovascular)
• Abd (abdomen)
• GU (genitali/rectal)
• MS/Ext (musculoskeletal and extremities
• Skin (integumentary)
• Neuro (neurologic)
• Laboratory Results (Labs)
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73. Pharmacotherapy Workup
• Are Always Generated as a Response to Two Basic Questions.
1. Is the patient's problem caused by drug therapy?
2. Can the patient's problem be treated with drug therapy?
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74. Activities and Responsibilities in the
Patient Care Process
Assessment (identifying DRP)
Construct Care plan
• Knowing the cause of a drug therapy problem helps to create the plan to fix it
• Disagreements common use judgment -
Follow-up evaluation
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75. Care Plan
• A care plan is the method by which the pharmacist helps the
patient achieve a pre--determined health care goal.
• Care plans MUST be developed cooperatively between the
pharmacist and patient.
• Physicians should always be informed, and usually be involved.
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76. Care Plan… Prioritizing a DTP
If a patient has ≥1 DTP, it is usually preferable to solve
them one at a time, not all at once.
Acute problems VS serious
problems
 #1 priority --DTP is acute and serious
 DKA, serious infection, stroke.
could be fatal,
Note: possibly be life threatening and there is no
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77. Care Plan… Prioritizing a DTP
 #2 priority --DTP is acute, but not serious
pain, diarrhea.
Not fatal, but patient hurts now
Note: may or may not be life threatening, but there is no
time to waste in solving it.
 #3 priority --DTP is serious, but not acute
HTN, diabetes.
May be fatal in the long run, but
Note: you have time to spare solving it.
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78. Care Plan… Prioritizing a DTP
Mini-case
• A patient comes to your private pharmacy seeking
therapy for a sunburn. You came to know that he is also
diabetic and takes metformin 500 mg bid which upsets
his stomach. His am sugars run 140-160mg/dL.
Identify and prioritize his
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79. Care Plan… Goals for pharmacotherapy
• Before you can develop a care plan, you must develop a
goal
• A goal is simply the outcome you want the patient to
achieve
• Who has goals for therapy?
• How are they stated?
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80. Care Plan… Goals
Your Goals Must be
• Measurable
• Achievable
• Considers your practice setting. Eg. HgBA1c
• Consistent with the pharmacist’s Responsibilities
Mini-Case:
A patient requires radiation for pain for bone mets CA. What
goal should the pharmacist set?
is radiation within our scope of practice????
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81. Care Plan… (Goals)
Your Goals should not be
• Vague or ill defined
E.g., a patient with HTN is poorly compliant with her Enalapril 5 mg
po bid. BP is 150/105.
Consider goals like “improve compliance” or “control blood
pressure.”
– Is compliance from 50% to 70% “improved”?
– Is BP decreased to 140/86 “ controlled”?
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82. Care Plan… (Goals)
• The best care plan is rarely the first one that comes to
mind, i.e., THINK before you act.
E.g. if Indocin upsets the stomach, saying “take it with
food” is not very useful if the better option is to discontinue the
drug.
• What do you want to do?
– Before answering, what are all your choices and which is
best/least bad?
• You may need to do additional research.
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83. Care Plan…
Drug focused care plans:
• Require a change in a patient’s drug therapy
• Usually require physician’s cooperation (unless OTC)
• Add a drug, d/c a drug, change a dose, dosing interval or dosage form
BE SPECIFIC
• --“Let’s start to our patient a beta blocker” is NOT a care plan
Rather :  Start him/her metoprolol 100 mg qd IS a care plan
• “to eliminate the orthostatic hypotension by holding enalapril for 1 day and
then reducing the daily dosage regimen of enalapril to 10 mg twice each day,
beginning on Tuesday.“
include the timeframe in which you expect to achieve each goal
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84. Care Plan…
Lifestyle related care plans:
• Stop smoking, lose weight, start exercising etc.
• the most difficult to implement and
• are generally best handled as part of a formal disease
management program, not a routine intervention.
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85. Care Plan…
Implementing
• Care plans require pharmacist’s action to implement
them
• You need to make sure that all parties:
 Agree with the care plan
 Understand who is responsible for what & when
 Are capable of complying with the care plan
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86. Care Plan…
Implementing… Question
• Does the patient agree with it and understand it?
• Does the patient have everything necessary to put the
care plan into action?
• Does the patient know when to follow up and with
whom?
• Does the patient agree to follow up if needed?
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87. Patient monitoring
• How else will you know if your goal has been
achieved?
• Make sure the patient knows you will be
following up.
• Consider when you will follow up, where, and
how (by phone, in person, by email, by appointment,
etc.)
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88. Exercise
• J.R is a 55 year old female with HTN, and ESRD. She is currently
receiving hemodialysis 3 times a week (MWF). She presents today
to the ER with complaints of general muscle weakness and a mild
fever. She also admits to palpitation and feelings of “a racing
heart” prior to hospital presentation. JR missed her dialysis
appointment because she felt tired, experienced flank pain, and
painful urination on Friday.
• PMH: HTN for 10 years – poorly controlled IDDM for 15 years,
ESRD for 5 years, and a history of chronic urinary tract infection.
• FH: Father died from a stroke 2 years ago, mother living with HTN
and CHF, grandmother with Diabetes and Asthma.
• SH: Smoker for 10 year (stopped 3 years ago), drinks alcohol
occasionally.
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89. Exercise…
• Allergies: Sulfa
PE:
GA:
Alert and oriented, but in mild to
moderate distress,
VS:
BP 155/89, HR 74, RR 18, T 37.2
• HEENT: WNL
• NECK: No JVD or swollen nodes
• LUNGS: Clear to auscultation
• CV: Peaked T waves and ST segment
depression
• ABD: Soft and non-tender, N & V
• GU: WNL
Laboratory tests today show:
• WBC = 10,500 mm3
• Cl = 108 mEq/L
• Glucose = 160 mg/dL
• Na =136 mEq/L
• CO2 =24 mMol/L
• Ca =6.6 mEq/L
• SCr =6 mg/dL
• K = 6.7 mEq/L
• BUN = 25 mg/dL
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90. Exercise…
Current Medications:
– Captopril 25 mg PO TID
– HCT/triamterene 1 capsule daily
– Human NPH Insulin 30 units SQ AM
Questions
– What subjective and objective data can you get from
this patient’s case.
– Make your assessment of the condition and
– formulate pharmaceutical care plan for the patient.
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91. Quiz
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92. 1. In what ways has the pharmacy practice changed in over the past 40
years? (2 points)
2. Explain the benefits of clinical pharmacy services in the health care
system? (2 points)
3. List common drug related needs and associated drug related problems
for each? (2 points)
4. Mentions risk factors for drug interactions? (2 points)
5. Compare and contrast direct and indirect measure of adherance? (2
points)
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93. 1. List different drug interactions classifications
systems?
2. List PK drug interactions and give examples
for each?
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