Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Mohammed A
B.pharm, M.clinpharm
Clinical pharmacist
27/10/2013 Mohammed A 1
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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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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Do we still need pharmacists? Ask yourself
Case-I
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Case-III
Case-IV
Case-V
• A women with unadjusted dose of anti Tb meds at a CrCl of 7.5
JUSH 2012.
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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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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
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What is Wrong with the Current/old System?
Cont…
Inadequate of Accountability?????
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What is Wrong with the Current/old System?
Cont…
The old
“Physicians Prescribe and Pharmacists Dispense” model
is no longer fully appropriate to
Other continents:
• Asia: India: Pharm.D: 2007
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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
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Why Now?
• HIV/AIDS is a major burden in developing countries
– 40 million people death because of HIV/AIDS
– Close to 3 million annually
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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
cure of a disease
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Background
• In the last 4 decades the trend in the pharmacy practice moved
from medicine supply more inclusive patient care
cost of Rx,
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Background...
• ‘Pharmacy’ believes clinically and financially in increased patient
care, but pharmacists have not fully adopted a new practice
philosophy.
• 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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Background...
• Communication skills
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Pharmaceutical Care - Benefits
• Decrease medication misadventures
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What is the Focus of the
New Pharmacy Curriculum?
• Clinical Application of Drug Therapy
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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.
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Medical Vs drug therapy problems
• So, how does this differ from a medical problem?
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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
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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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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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Drug-related needs Categories of drug therapy
problems
INDICATION 1. Unnecessary drug
therapy
2. Needs additional drug
therapy
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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
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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?
4. Is the patient able and willing to comply with the drug therapies as instructed?
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Common Causes of Drug Therapy
Problems
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1. Unnecessary drug therapy
• Addiction/recreational use
• Preventive/prophylactic DT is required
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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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Clinical Questions to consider
• Is there an untreated indication? Why?
• Incorrect storage
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5. Dosage too high
• Dose is too high
• The dose administered too rapidly Wrong dose
• Undesirable effect.
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Questions
• Is there evidence of adverse effects or drug allergies?
• Are the medications being stored properly and are any past
their expiration dates?
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7. Inappropriate compliance
• The patient does not understand the instructions.
• The drug is not available for the patient. psychiatry, cardiac, statins
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Questions
• Is the patient misusing medication, whether
unintentionally or deliberately?
• DM • Asthma
• Arthritis • Anxiety
• Depression • Hyperlipdemia
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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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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?
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Mini-cases…
• Case-3: A child with chronic, persistent asthma is being treated
with nebulized albuterol treatments four times daily.
Case-5: A patient who travels for work keeps his insulin in the car’s
glove compartment.
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Steps in the Pharmaceutical Care Process
1. Developing a profession relationship with the patient
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Actual and Potential Drug Therapy Problem
a. An actual problem
– Is one that has already occurred. Action should be taken to resolve it.
b. A potential problem
Is one that is likely to occur.
Potential problems have not occurred.
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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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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:
Communications tips
• Docs do not care about drug therapy problems. They care about
problems
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Actual and Potential DTP… (Communications tips)
Mini-case:
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
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SOAP Notes
PC practitioners collect two types of data to help them evaluate and
mange patients’ drug therapy:
Subjective data
– Cannot be directly measured
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SOAP Notes…
Objective data
• Typically numerical
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SOAP Notes…
Chief complaint (C/C)
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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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SOAP Notes…
usually omitted.
– For deceased relatives, the age and cause of death are recorded
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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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SOAP Notes…
Review of Symptoms (ROS)
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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.
– GA (general appearance)
– VS (vital signs)-blood pressure (BP), pulse(PR), respiratory rate (RR),
temperature (T)
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SOAP Notes ROS …
• HEENT (head, eyes,ears, nose, and throat)
• Lungs/Thorax (pulmonary)
• Cor or CV (cardiovascular)
• Abd (abdomen)
• GU (genitali/rectal)
• Skin (integumentary)
• Neuro (neurologic)
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Activities and Responsibilities in the
Patient Care Process
Assessment (identifying DRP)
Follow-up evaluation
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Care Plan
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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.
could be fatal,
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Care Plan… Prioritizing a DTP
Mini-case
DTP’s?????????
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Care Plan… Goals for pharmacotherapy
• Before you can develop a care plan, you must develop a
goal
achieve
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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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Care Plan… (Goals)
Your Goals should not be
• Vague or ill defined
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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.
BE SPECIFIC
• --“Let’s start to our patient a beta blocker” is NOT 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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Care Plan…
Lifestyle related care plans:
• Stop smoking, lose weight, start exercising etc.
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Care Plan…
Implementing
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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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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.
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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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Quiz
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1. In what ways has the pharmacy practice changed in over the past 40
years? (2 points)
3. List common drug related needs and associated drug related problems
for each? (2 points)
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