Clinical pharmacy practice focuses on achieving quality use of medicines through a patient-centered approach. It involves pharmacists participating in patient management as part of a multidisciplinary healthcare team. Pharmacists apply evidence-based knowledge to identify and reduce risks associated with medication use, educate patients, and conduct research. The goal of pharmaceutical care is to ensure patients receive drug therapy that is appropriately indicated, effective, safe, and convenient through monitoring and resolving any drug therapy problems. This is achieved using the pharmaceutical care cycle which includes assessing patient needs and drug therapy, developing and implementing a care plan, and evaluating outcomes.

1. HHSC
Department of Pharmacy
The Practice of Clinical Pharmacy
March,2023
Chala D. (B. Pharm, MSc.in Clinical Pharmacy)

2. Introduction
 Pharmacy practice is;
o moving toward a model that integrates patient-
focused care (also known as patient centered
care) and drug distribution services
 The term clinical pharmacy historically
described
o patient oriented rather than product-oriented
pharmacy practice
2 3/12/2024

3. Intro….
 Clinical pharmacy practice
 is a practice of pharmacy as a part of a
multidisciplinary health care team directed at -
achieving quality use of medicines
How ?
o Participation in the management of individual
patients
o Application of the best available evidence in daily
clinical practice
o Contribution of clinical knowledge and skill to
health care team
3 3/12/2024

4. Cont’d…
o Identification and reduction in risks
associated with medicine use
o Involvement in education of patients,
attendant and other health professionals
o Involvement in research
4 3/12/2024

5. Cont’d ….
 The term clinical pharmacist was used to
describe a pharmacist whose primary job
was
o To interact with the health care team
o Interview and assess patients
o Make patient specific therapeutic
recommendations
o Monitor patient response to drug therapy
and
o Provide drug information
5 3/12/2024

6. Pharmaceutical care (PC)
 Definition
o is the responsible provision of drug therapy
for the purpose of achieving definite
outcomes that improve or maintain patient’s
quality of life”
 The four outcomes identified include the
following:
o Cure of disease
o Elimination or reduction of symptoms
o Arrest or slowing of a disease process
o Prevention of disease or symptoms
6 3/12/2024

7. Pharmaceutical care (PC)…
Pharmacists tasks is to ensure;
o Pts drug therapy is appropriately indicated,
the most effective available, Safest possible
and convenient for the pt.
 A pharmacist practices PC
o when he/she finds and fixes or prevents drug
therapy problems in patients.
7 3/12/2024

8. PC Cont’d…
 What required is ?
o Expert knowledge of therapeutics
o A good understanding of disease process
o Knowledge of pharmaceutical products
o Drug monitoring skills
o Provision of drug information
o Strong Communication skills
8 3/12/2024

9. PC cont’d…..
9 3/12/2024

10. Cont’d…
 Pharmaceutical Care - Benefits
o Decrease medication misadventures
o Increase patient compliance to therapy –
o Empowers patients to take in-charge of their
own health and treatment
o Decrease healthcare cost
o Decrease morbidity/ mortality
o Increase patients’ quality of life
10 3/12/2024

11. PC cont’d…
Pharmaceutical Care – How can be performed
?
 Through Patient care process -
o Assess needs
o Identify problems
o Develop care plan
o Implement plan
o Monitoring - evaluation for efficacy & safety
11 3/12/2024

12. The Pharmaceutical Care Cycle
12 3/12/2024

13. Activities and Responsibilities in the
Patient Care Process
 Assessment
 (assess drug related needs & identifying DTP)
 Construct Care plan
o Knowing the cause of a drug therapy problem
helps to create the plan to fix it
 Follow-up evaluation (monitoring)
13 3/12/2024

14. Assessment
 A systematic review of the patient’s drug-
related needs
 Performed by the pharmacist with the
patient to ensure that;
o all drug therapy is indicated, effective,
safe, patient is compliant, and
o to identify drug therapy problems (DTP)
14 3/12/2024

15. Asses…
 The assessment interview influences all
other components of the patient care
process
o It influences communication,
o data accuracy,
o clinical decision-making,
o ethical judgments,
o patient compliance, patient satisfaction,
o practitioner satisfaction, and
o clinical outcomes
15 3/12/2024

16. Asses…
 Skills required
o inquiry, listening, and observational skills
 Responsibilities during assessment
o developing the therapeutic relationship
o assessing drug-related needs
o identifying drug therapy problems
16 3/12/2024

17. Asses…
Developing the therapeutic
relationship
oMeeting and greeting your patient
oIntroduce yourself as a pharmacist
oDetermine the patient’s primary spoken
language
odemonstrating genuine interest in the
person acceptance, and establishing
rapport
17 3/12/2024

18. Asses…
o Address people using their preferred
name
o A semi-private or private space must
be provided for you to conduct an
assessment of your patient's drug-related
needs
o Keep the area clean and organized
18 3/12/2024

19. Collecting Relevant Patient-Specific
Information
 The practitioner collects relevant patient-specific
information
o to use in decision making concerning all
drug therapies
 Only data that are required and used by the
practitioner are elicited from the patient
19 3/12/2024

20. Asses…
Information elicited during Assessment
 Patient Demographics
o needed to see each patient as a unique individual
Age of the Patient
o Importance of age
o To determine whether drug therapy is indicated
or not
o Medical problems and goal of therapy varies by
age
o To select appropriate product and dosage form
20 3/12/2024

21. Asses…
 Drug dosing
o Dosage requirements vary greatly with age
o Absorption, metabolism, and elimination of
most drugs changes with age
Gender
 Importance
 To determine risk of the patient for the
disease
o Hypothyroidism, anemia, and osteoporosis requiring
drug therapy are more common in females
21 3/12/2024

22. Asses…
 Drug selection
 Height and Weight
o used for dosage individualization
 Body surface area (m2) = ((height in cm) x
(weight in kg/3600))1/2
22 3/12/2024

23. Asses…
Living Situation
o occupation and socioeconomic status can have
a dramatic influence on drug-related needs and
subsequent outcomes
o Who lives with the patient and who cares for
the patient?
o Who is responsible for administering
medications and making health care decisions?
23 3/12/2024

24. Asses…
 Do other family members have a history of
certain diseases, or other risk factors
(smoking, alcohol use);
that may negatively affect your patient's drug
therapy outcomes for
o (coronary artery disease, depression)?
Pregnancy and Breast-Feeding
o Affects drug selection
24 3/12/2024

25. Asses…
The medication experience(ME)
• is the patient's personal approach to taking
medication
• ME is the sum of all the events in a patient's life
that involve medication use
• The medication experience is first and
foremost;
• the patient's beliefs, perceptions,
understandings, attitudes, and behaviors
about drug therapy
25 3/12/2024

26. Asses…
 The medication experience includes more
technical aspects as well;
o the patient's current medications, social drug
use, immunizations, allergies, and medication
history
 Includes the patient's preferences, attitudes,
general understanding of his or her drug therapy,
concerns about it,
o expressed expectations of desired outcomes,
and the patient's medication taking behavior
26 3/12/2024

27.  You will need to inquire and make
judgments about the following questions:
o What is your patient's level of understanding
of his/her disease or illness, drug therapies,
and therapeutic instructions?
o What concerns does your patient have about
his/her health in general or medical conditions
and drug therapies in particular?
27 3/12/2024

28. Asses…
 What concerns does your patient have
about side effects, adverse events or allergies?
 What does your patient dislike about his/her drug
therapies?
 To what extent does your patient want to be an active
participant in his/her care?
 To what degree is the cost of drug therapy, clinic visits,
hospitalizations, or treatment failures, a concern for
your patient?
28 3/12/2024

29. Asses…
 Medication History
 include immunization status, social drug use,
allergies, adverse reactions and other special
needs, and
 a history of relevant medication use
 History of relevant medication use
o to determine if the present problem has been
treated before with medications
o to determine previous treatment failures and
unwanted SE to medications used in the past
29 3/12/2024

30. Asses…
Current Medication Record
 includes:
 (1) the indication for drug therapy;
 (2) all of the drug products your patient is
taking for that indication;
 (3) specifically how the patient is actually
taking them; and
 (4) the patient's response to the drug therapy
30 3/12/2024

31. Asses…
 Indication can be for
 Cure a disease or illness;
 Prevent a disease or illness;
 Slow the progression of a disease or illness;
 Supplement nutritional, electrolyte, hormonal,
or other deficiencies;
 Correct abnormal laboratory test results;
31 3/12/2024

32. Asses…
Chief Complaint(s)
o The one or more symptoms or concerns
causing the patient to seek care
The history -
 severity, context, location, quality, timing,
modifying factors, and associated signs and
symptoms
 Includes patient’s thoughts and feelings
about the illness
32 3/12/2024

33. Asses…
History of Present Illness
 Amplifies the Chief Complaint, describes how
each symptom developed
 May include medications, allergies, habits of
smoking and alcohol, since these are
frequently pertinent to the present illness
33 3/12/2024

34. Asses…
 Past Medical History
 information about past serious illnesses,
hospitalizations, surgical procedures,
pregnancies, deliveries, accidents or injuries
Important to identify
o risk or predisposition to develop a serious
condition
o a contraindication to future drug therapies
34 3/12/2024

35. Asses…
Review of Systems
 is a survey of various bodily systems to
uncover significant symptoms or problems
(drug-related)
o that have not already been revealed
during the assessment interview include
o physical findings,
o descriptions and experiences offered by
your patient, and
o laboratory values
35 3/12/2024

36. Asses…
Subjective Data
o What the patient tells you
o From patient demography to review of systems
 Example: Mr. Dhuguma is a 35-year-old driver
who complains productive cough with blood
strike sputum for the past three weeks
36 3/12/2024

37. Asses…
Objective Data
o What you detect on the examination
o All physical examination findings
 Example: vital sign
o BP - 160/80, HR – 96bpm, respiratory rate - 24
37 3/12/2024

38. Cont’d …
 Usual Physical
Assessment
Sequence
 1. Vital signs
 2. Appearance and
behavior
 3. Skin
 4. Head
 5. Eyes
 6. Ears
 7. Nose
 8. Mouth
 9. Neck
 10. Breasts
 11. Chest and lungs
 12. Heart
 13. Abdomen
 14. Extremities
 15. Back and spine
 16. Nervous system
 17. Mental status
 18. Genitalia and
rectum
38
3/12/2024

39. Review of Laboratory and Diagnostic
Tests
 Data from laboratory and diagnostic tests
and procedures provide important
information
o Regarding the response to drug therapy
o The ability of patients to metabolize and
eliminate specific therapeutic agents
o The diagnosis of disease, and
o The progression and regression of disease
39 3/12/2024

40. Assessment of Drug-Related Needs
Determine if the patient's drug-related needs
are being met:
 all the patient's medications are appropriately
indicated
 most effective available
 safest possible and
 patient is able and willing to take the
medication as intended
40 3/12/2024

41. Asses…
Evaluating the Appropriateness of the
Indication for the Patient's Drug Therapy
o make the connections between the
indication (medical condition), the drug
product, the dosage regimen, and the
outcome
o If the patient has an inappropriate
indication or needs drug therapy
o then you have identified a drug therapy
problem
41 3/12/2024

42. Asses…
Determining the Effectiveness of the Drug
Regimen
 Effectiveness is determined by evaluating the
patient's response compared to the desired
goals of therapy for each indication
 To evaluate effectiveness you should have
established goals of therapy
 When the drug therapy is not effective for the
patient: wrong product or too low dosage
42 3/12/2024

43. Asses…
Establishing the Safety of the Drug Regimen
o adverse drug reactions and/or toxicities
 dose-related problems are resolved by
lowering the dose,
o while those reactions not dependent on the
amount of a drug the patient takes are resolved
by switching to another drug product
43 3/12/2024

44. Asses…
Understanding Patient Compliance
o describes the behavior of the patient
o Check whether your patient is able and willing
to take medication
o Does the patient taking the medication as
prescribed?
44 3/12/2024

45. Drug Therapy Problem
 A drug therapy problem is any undesirable
event experienced by a patient
o which involves, or is suspected to involve,
drug therapy, and that interferes with
achieving the desired goals of therapy
 1. An undesirable event or risk of an event
experienced by the patient may be
o medical complaint, S/S, Dx, illness,
impairment, disability, abnormal laboratory
value, or syndrome
45 3/12/2024

46. Cont’d …
The problem
 The drug therapy (products and/or dosage
regimen) involved
 The relationship (exists or is suspected to exist) b/n the
undesirable patient event and drug therapy
 The r/n ship can be
 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
46 3/12/2024

47. Components of a 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
47 3/12/2024

48. DTP…
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
48 3/12/2024

49. Drug-related needs Vs Categories of drug
therapy problems
 Patients need every medication they are taking to
have an appropriate indication
 If a drug does not have an appropriate indication, the
DTP “unnecessary drug therapy” will be identified. OR
 Un treated indication – The DTP is Need
additional DT
 Patients need their drug therapy to be effective
 When a patient’s need for medication to be effective
is not met, two possible DTPs can arise
 They are “Ineffective drug” and “dosage too low”
49 3/12/2024

50. Drug related Needs Vs DTP Cont’d …
 Patients need their drug therapy to be safe
 Not meeting a need for medication safety can result in
 the DTPs of “dosage too high” or “adverse drug
reaction
 Patients need to be able to comply with drug
therapy and other aspects of their care plans
 Not meeting a need for compliance can result in the drug
therapy problem of “noncompliance” results
50 3/12/2024

51. Summary - Needs Vs DTP
 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
51 3/12/2024

52. Identifying Drug Therapy Problems
 A PC practitioner should have a tacit of
understanding of the common causes of DTPs
 identification is the essence of PC practice
 the practitioner & patient can rationally
construct a care plan to resolve that DT
problem
 And achieve his/her goals of therapy
52 3/12/2024

53. Cont’d…
 DTPs that are identified during the assessment
process,
 can be resolved through individualized changes
in the patient's drug therapy regimens.
 Using
o knowledge d/se, identified in the assessment step
of drug therapy Information
 The synthesis and application of this knowledge
occurs in a logical, systematic manner using the
Pharmacotherapy Workup
53 3/12/2024

54. The Process Used to Identify Whether or Not
the Patient Is Experiencing a DTP
 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?
54 3/12/2024

55. Common Causes of Drug Therapy Problems
 1. Unnecessary drug therapy
no valid medical indication
duplication of therapy
Non-drug therapy more appropriate
Treating an avoidable ADR associated with
other drug
Addiction/recreational use
55 3/12/2024

56. Cont’d …
 2. Need for additional drug therapy
condition requires initiation of DT
Preventive/prophylactic DT is required
additional DT for synergistic/additive effects
 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?
56 3/12/2024

57. Cont’d…
 3. Ineffective drug
The drug product is not the most effective
for medical condition
The medical condition is refractory to the
drug product.
The dosage form of the drug product is
inappropriate.
57 3/12/2024

58. Cont’d…
 4. Dosage too low
The dose is too low to produce the desired
response.
The dosage interval is too infrequent to
produce the desired response.
The duration of drug therapy is too short to
produce the desired response.
A drug interaction reduces the amount of
active drug available
58 3/12/2024

59. Cont…
5. Dosage too high
 Dose is too high
 The dosing frequency is too short
 The duration of drug therapy is too long
 A drug interaction occurs resulting in a toxic
reaction to the drug product
59 3/12/2024

60. Questions to consider
 Are the dose, dosage interval and duration of
therapy
 appropriate for each medication the patient is taking?
 How long has the patient been receiving the
current dose of each medication?
60 3/12/2024

61. Questions to consider
 Is there evidence of adverse effects that is
dose related ?
 Are medications being administered correctly?
 Are there any potential or actual drug
interactions?
61 3/12/2024

62. 6. Adverse drug reaction
 The drug product causes an undesirable reaction that is
not dose-related
 A safer drug product is required due to risk factors
 A drug interaction causes an undesirable reaction that is
not dose-related
 The dosage regimen was administered too rapidly
 The drug product causes an allergic reaction
 The drug product is contraindicated due to risk factors
62 3/12/2024

63. 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.
 The drug is too expensive for the patient.
 The drug is not available for the patient.
63 3/12/2024

64. Questions to consider
 Is the patient complying with drug therapy, and
if not, why not?
 If the patient finds a therapy too expensive,
what alternatives are possible?
 What are the possible disadvantages to
switching therapy?
64 3/12/2024

65. Actual and Potential Drug Therapy
Problem
 An actual problem
is one that has already occurred. Action
should be taken to resolve it
 A potential problem
is one that is likely to occur.
The necessary steps should be taken to
prevent it before deciding to contact the
prescribing physician, they should consider
how severe the consequences of the
potential problem could be
65 3/12/2024

66. Stating Drug Therapy Problems
 Describe your patient's drug therapy problem in a
concise, accurate, and informative manner
 A statement describing the patient's drug therapy
problem(s) consists of three components:
 A description of the patient's medical condition
 The drug therapy involved
 The specific association between the drug therapy
and the patient's condition
66 3/12/2024

67. Stating DTP Cont’d …
 “the drug she is taking for her high cholesterol is
not working.“
VS
 "The Lipitor (atorvastatin) therapy that she has
been taking for the past 3 months for
hyperlipidemia has only resulted in a 5%
reduction of her total cholesterol using an
aggressive dosage of 80 mg daily."
67 3/12/2024

68. Documenting Drug Therapy Problems
 Each problem identified is added to the
patient's record and includes;
 the medical condition, illness, or complaint
involved, the drug therapy or therapies
involved, and the likely cause of the drug
therapy problem
 Drug therapy problems are documented within
the care plan for each medical condition
involved
68 3/12/2024

69. Documenting Drug Therapy Problems
 The interventions required
to resolve the drug therapy problem will also be
associated with that care plan
 The action that was taken
(increase dosage, discontinue drug therapy, add
preventive drug to regimen) also needs to be
recorded.
69 3/12/2024

70. Prioritizing a DTP
 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
o #1 priority –
o DTP is acute and serious (DKA, serious
infection, stroke). could be fatal,
o Note: possibly be life threatening and there
is no time to waste in solving it
70 3/12/2024

71. Cont’d…
 Prioritizing a DTP
 #2 priority --DTP is acute, but not serious (pain,
diarrhea).
o Not fatal, but patient hurts now
o 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).
o May be fatal in the long run, but
o Note: you have time to spare solving it
71 3/12/2024

72. 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.
72 3/12/2024

73. Care plan …
 “The structure of care plan functions as;
- a frame work for the cooperative efforts of all those
involved in the management of a patients medication.
 Components
 Developing goals of therapy
 Statement of intervention
 Follow-up evaluation
73 3/12/2024

74. 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?
74 3/12/2024

75. Cont’d …
 Your Goals Must be;
o Measurable,
o Achievable ,
o Considers your practice setting
o Consistent with the pharmacist’s Responsibilities
75 3/12/2024

76. Cont’d….
 The best care plan is rarely the first one that
comes to mind, i.e., THINK before you act.
 What do you want to do? –
o Before answering, what are all your choices and
which is best/least bad?
 You may need to do additional research
76 3/12/2024

77. Cont’d …
Drug focused care plans:
o Require a change in a patient’s drug therapy
o Usually require physician’s cooperation (unless OTC)
 Add a drug, d/c a drug, change a dose, dosing interval
or dosage form
 BE SPECIFIC –
o “Let’s start to our patient a beta blocker” is NOT a
care plan
o Rather : Start him/her metoprolol 100 mg qd - IS a
care plan
77 3/12/2024

78. Cont’d…
 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
78 3/12/2024

79. Implementing / Intervention
 Care plans require pharmacist’s action to implement
them
 You need to make sure that all parties:
o Agree with the care plan
o Understand who is responsible for what & when
o Are the patient capable of complying with the care
plan?
79 3/12/2024

80. Cont’d …
 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?
80 3/12/2024

81. 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.)
81 3/12/2024

82. THANK you !!!
82 3/12/2024