PHARMACIST CARE

MANUAL
 Old Perceptions of Pharmacists

The discipline of pharmacy embraces the knowledge on synthesis, chemistry and

preparation of drugs
 Development of clinical practice in pharmacy

The emergence of clinical pharmacy as a form of professional practice has been attributed
to the poor medicines control systems that existed in hospitals during the early 1960s.
 Clinical pharmacy

■ Clinical pharmacy comprises a set of functions that promote the safe, effective and
economic use of medicines for individual patients.

Shift towards direct engagement

to maximize the benefits that
individuals obtain from the
medicines they take.
Product oriented role Patient centered role

■ Optimizing the use of medicines requires a patient-centered approach that is

grounded in principles of safety, evidence-based and consistent practice, and an
understanding of the patient’s experience.
 Evolution in the practice of pharmacy

1 Compounding drugs 6 Pharmaceutical care

2 Dispensing drugs 5 Clinical pharmacy

3 Patient education & provider 4 Medication profile

of drug information review

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 Pharmaceutical care

• Is the “responsible provision of drug therapy for the purpose of achieving

definite outcomes that improve a patient’s quality of life” (Hepler and Strand,
1990).

• It is a cooperative, patient centered system for achieving specific and positive

patient outcomes from the responsible provision of medicines.

• The delivery of pharmaceutical care is dependent on the practice of clinical

pharmacy, but the key feature of care is that the practitioner takes
responsibility for a patient’s medicines-related needs and is held
accountable for that commitment.
Aim or function of pharmaceutical care

Identifying
potential and
actual drug-
related problems

Preventing drug- Resolving actual

related drug-related
problems. problems
 Practicing Pharmaceutical Care

Establish a full medication history and highlight

Assessment actual and potential medication-related problems.

Clearly state the goals to optimize care & the

Care plan responsibilities of both pharmacist & patient in
attaining the stated goals.

Review progress against the stated patient

Evaluation outcomes.

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1- ASSESSMENT
 The Purpose of Assessment

■ The purpose of the assessment is three fold.

1. To understand the patient well enough to make rational drug therapy

decisions with and for him/her.

2. To determine if the patient’s drug therapy is appropriate, effective and

safe, and to determine your patient’s compliance with his/her
medication regimens.

3. To identify drug therapy problems.

 Identify DRP

■ A DRP is an event or circumstance involving medication therapy that

actually or potentially interferes with an optimum outcome for a
specific patient.

■ Identify DRP, to either resolve actual or prevent potential drug

related problems is the primary function of pharmaceutical care
practice.

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 How to conduct the assessment?

Assess & analyze

patient data to
Collect data for Identify DRP &
determine if the
decision making non-adherence
patient’s drug
related needs

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 ESTABLISH THERAPEUTIC
RELATIONSHIP AND COLLECT
PATIENT RELATED DATA
 1.1 Establish a therapeutic relationship

■ Meet patient
– Greeting
– Address with respect
– Introduce self and explain your role in his care
– Effective communication

■ Interview patient

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1.2 Data collection (patient database base model)

■ The type of information the pharmacist needs to make informed

drug therapy decisions is best understood by using the
Pharmacist’s Patient Data Base Model.

■ This model organizes patient information into six categories.

■ You do not always have to gather all of the information listed in

this model

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 Demographic

■ Name
■ Age (Date of birth) ■ The patient’s age is important in
determining the correct dosage of
■ Address
medications, especially when you are
■ Sex dealing with elderly or pediatric patients
■ Religion and ■ Religion can also be important (e.g. Muslims
religious affiliation do not take pork insulin)
■ Occupation ■ Occupation can also be important

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 Administrative

■ Physicians  To identify and locate a patient, medical

records, and MD
■ Room/bed
numbers  Consent form may be needed in cases
when using medications with a high
■ Consent forms incidence of adverse effects
■ Patient
identification
number

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 The Medical data

1. Chief Complaint
■ The medical history, generally obtained by a
2. History of Present physician, is read and interpreted by the
Illness pharmacist.
3. Past Medical History
4. Medications ■ Then, by integrating pharmaceutical knowledge
5. Allergies with interviewing skills, the pharmacist
questions the patient about specific problems
6. Family History associated with use of the medications.
7. Social History
8. Review of Systems

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 The medical data

Family history (FH) Familial diseases in first degree relatives

Social history (SH) Who lives with the patient?

Lifestyle- exercise, nutrition, eating habits
Abuses– tobacco, alcohol.
Employment– current and recent changes
 The medical data

Allergies (ALL) Medications or food

 The Medical Data
Chief • Why the patient is sitting in front of you
Complaint • Usually stated in the patient’s own words
(CC) • May need to let patient talk for a while before true reason
emerges
 The medical data
History of • Expand on the patient’s chief complaint.
Present Illness • This is the story of the patient’s problem.
(HPI) • Start general and become more specific.
• Begin with open-ended questions as you used to get the
chief complaint:
• Tell me more about the pain.
• What else is going on?
• What was that like for you?
 HPI – LOCTAES

L: Location Where is the problem? Does it move or radiate?

O: other symptoms Associated symptoms, Other new symptoms that may not be related, to help
you rule in or rule out disease
C: characteristics Quality of the symptom? Get the patient to use their own descriptive words if
possible. What does it feel like? Use descriptive words– throbbing, burning,
stabbing, crushing, etc
A: aggravating or What makes it better? What makes it worse? What has the patient done to try
alleviating factors to feel better? Over the counter medications? Friend’s medication? Therapies?

T: timing When did it start? Is it intermittent or continuous? How long does each episode
last? Does the symptom vary with time of day? Have you ever experienced this
before?
E: environment What places or events affect the symptom? Work vs. home. Leisure activities.
Diet. Emotions. Heat, dust, altitude
S: severity How is the symptom interfering with the patient’s daily functioning?
If the patient has pain, how bad is the pain on a scale of one to ten?
 The medical data
Past Medical • Chronic medical problems, hospitalizations
History • Surgical or trauma history
(PMH) • Childhood illnesses
• Gynecologic history
 The medical data
Review of A screening device to uncover potentially significant symptoms not otherwise
symptoms elicited, “head to toe.”
(ROS) The primary purpose of the review of systems is to identify any other or
additional drug-related needs.
It is usually performed as the last part of the medical history.
 The medical data
Medicine name and indication (Purpose)
Dose
Medications Dosage regimen (Dose, Route, Frequency, duration,
timing)
Side effects
Taking as prescribed?
Cost issues
 Medications
Don’t forget!

 Over the counter medications

 Vitamins
 Nutritional supplements

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 Where to find information for the pharmacist
patient data base

■ A Patient medical chart or

record
■ The patient
■ Health care providers
■ Other people
 Pharmaceutical Care- Patient Drug Related Need

Medication is Medication is Medication is

appropriate Effective Safe

Patient is Adherent
Treatment Related Problems Worksheet
 Description of a Drug Therapy Problems Categories

Red box reflects

effectiveness

Green box reflects

safety
 Examples

A 55-year-old has been successfully treated for his first episode of a duodenal ulcer with
ranitidine 150 mg orally twice daily for the past 4 weeks. He is also using cimetidine, which
he purchased without a prescription.

Duplicate therapy
 Examples

A 55-year-old has been successfully treated for his first episode of a duodenal ulcer with
Ranitidine 150 mg orally twice daily for the past 8 weeks. He presents to the pharmacist
requesting a refill of his prescription to continue ranitidine at that dose.

No Medical Indication
 Examples

Overweight (BMI= 25.5 kg/m2) with no risk factor (DM. HTN, dyslipedemia, or sleep apnea)
patient taking Xenical (Orlistat).

Non-Drug therapy is more appropriate

 Examples

A 66-year-old retired executive who has stable coronary disease and not taking aspirin to
reduce his risk of developing a myocardial infarction and cardiovascular mortality.

Preventive Therapy
 Examples

A patient with sever major depressive disorder and suicidal thoughts not taking
antidepressants.

Untreated Condition
 Examples

A 54-year-old woman borrowed a sample of Salmeterol from a friend down the street who
also has asthma. She has been using it to relieve her own acute asthmatic episodes, which
occur about once a week.

More Effective Drug available

 Examples

Patient with advanced heart failure resistance to loop diuretic should add thiazide diuretic to
his treatment (The addition of a thiazide diuretic to treatment with loop diuretics will usually
establish a diuresis even in patients not responsive to other diuretic regimens).

Condition Refractory to Drug

 Examples

A 45 kg girl with her first episode of acute otitis media is prescribed amoxicillin suspension 40
mg orally (40 mg/5 mL) three times a day for 10 days

(recommended dose for children ≥ 40kg: 500 mg every 8 hours, 750 mg to 1 g every 12 hours
and for severe infections 750 mg to 1 g every 8 hours for 10 days).

Ineffective Dose
 Examples

A 45 kg girl with her first episode of acute otitis media is prescribed amoxicillin 20 mg/kg
suspension once daily for 10 days

(recommended dose for children ≥ 40kg: 500 mg every 8 hours, 750 mg to 1 g every 12 hours
and for severe infections 750 mg to 1 g every 8 hours for 10 days).

Frequency Inappropriate
 Examples

A patient with severe lower respiratory tract infection is taking amoxicillin/clavulanate

500/125 mg PO q8hrs for 3 days.

(recommended dose should be given for 7-10 days).

Duration Inappropriate
 Examples
ACE inhibitors causing dry cough or hyperkalemia

Amlodipine causing edema

Verapamil causing constipation

Undesirable Effect
 Examples

Beta blockers in uncontrolled (decompensated) heart failure.

Verapamil in patient with heart block

Unsafe Drug
 Examples

Aspirin with clopidogrel increase bleeding effect.

Propranolol given with Verapamil may cause AV block

Drug Interaction
 Examples

Penicillin Allergy

Allergic Reaction
 Categories and Common Causes of Drug Therapy Problems
Drug therapy Drug therapy problem cause
problem category
Dose too high: the dose of the drug is too
high for the patient, resulting in toxicity.
Frequency too short: the dosing frequency
is too short for the patient.
Dosage too high Duration too long: the duration of drug
therapy is too long for this patient.
Drug interaction: a drug interaction
increases the amount of active drug
available resulting in toxicity in this patient.
Examples
High dose of digoxin results in bradycardia
and second degree heart block
Patient with HTN is taking Atenolol 50mg PO/
three times daily (should be taken 0nce daily)
Antibiotics for several months
Warfarin interaction with clarithromycin
(Inhibition of the cytochrome P450 oxidizing
system appears to be the reason for the
increase)
 Categories and Common Causes of Drug Therapy Problems

Drug therapy problem category Drug therapy problem cause

Patient prefers not to take: the patient prefers not to take the drug
therapy as instructed.
Adherence
Patient forgets to take: the patient does not remember to take
sufficient doses of the medication.
 Categories and Common Causes of Drug Therapy Problems

Drug therapy problem Drug therapy problem cause

category
Drug product not available: sufficient supply of the drug product is not
Adherence available to the patient.
Cannot swallow/administer drug: the patient is not able to swallow or
administer the drug therapy as intended.
 Categories and Common Causes of Drug Therapy Problems
Drug therapy Drug therapy problem cause
problem category
Does not understand instructions: the
patient does not understand how to
properly take or use the drug product
Adherence and dosage regimen.
Cannot afford drug product: the patient
cannot afford the drug therapy
recommended or prescribed.
Examples
A patient hospitalized with severe COPD was
not adherent to tiotropium inhaler after
discharge, because she did not understand the
instructions
Xeljanz (tofacitinib) for rheumatoid arthritis
price is 1130.46 JOD
2- CARE PLAN
 Components of care plan

■ The following four components comprise the pharmacist's care plan:

1. Identify therapeutic goals which are definite (predefined) drug-

related therapeutic outcomes.

2. Recommended therapy (intervention)

3. Follow up/ evaluation  efficacy mainly & safety

4. Monitoring plan  safety

 Care plan example

Medical Therapeutic Drug therapy Recommendations Monitoring Follow-Up Plan

Condition Goals problem and Interventions Parameters

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 Goals of Therapy

■ “ I hope you feel better soon.”

■ What is meant by feel better? When is soon?

■ A goal of therapy might be stated as

– "The patient's elbow pain will be eliminated within 24 hours," or
– "The patient's diastolic blood pressure will be below 85 mmHg within 30 days,"or
– "The patient will have no more than two episodes of seizures within the next
month," or
– "The patient's serum potassium will increase to between 3.5 and 4.5 meq/L within 48
hours."

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 Goals of Therapy
■ Goals of therapy have the qualities of being:
– Realistic
– Observable
– Measurable
– describable by the patient and/or the practitioner.
■ Patient-specific goals of therapy also must be associated with a timeframe
describing when each goal should be achieved.
– This timeframe is important to your patients as it lets them know what to
expect and when to expect it.
– Also serves as a guide to establishing an appropriate schedule for you and
your patient for follow-up

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 Categories and Examples of therapeutic goals which are
definite (predefined) drug-related therapeutic outcomes.

a. Cure a disease e.g. infection, diarrhea

b. Reduce or eliminate signs and/or symptoms e.g. depression, allergic
rhinitis and common cold
c. Slow the progression of a disease e.g. DM, HF, IHD
d. Prevent a disease e.g. osteoporosis and MI
e. Normalize laboratory values e.g. hypokalemia, anemia

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 Interventions
■ Interventions that will help the patient to achieve the desired goals of therapy
 used to develop care plan.

■ These interventions:
1. Resolve any drug therapy problems identified during the assessment
2. Optimize the patient's medication experience
3. Prevent drug therapy problems.

 It is important to include the patient at each step in your decision making

process.

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3- EVALUATION
 Evaluation
1. Evaluate actual outcomes

2. Determine patient’s progress toward achievement of goals of therapy

3. Determine if there are any safety or non compliance issues present

4. Assess whether any new DRP have developed.