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
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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
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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
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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
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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
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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.
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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
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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
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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
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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?
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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?
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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
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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
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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;
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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
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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”
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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
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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
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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
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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
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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?
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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
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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?
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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.
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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
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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
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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?
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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?
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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
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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.
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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?
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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
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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
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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."
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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
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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.
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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
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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
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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.
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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
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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?
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75. Cont’d …
Your Goals Must be;
o Measurable,
o Achievable ,
o Considers your practice setting
o Consistent with the pharmacist’s Responsibilities
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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
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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
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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?
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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?
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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.)
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When you identify and describe a patient's drug therapy problem, you are adding new and unique information about the patient's case. Therefore, it is important to
