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Pharmaceutical care
- 1. 12/28/2012 1 Pharmaceutical Care Malik Allah Bukhsh Awan Lecturer IPS Objectives ā¢ To differentiate between traditional pharmacy / Clinical Pharmacy & Pharmaceutical Care ā¢ Process of Pharmaceutical care ā¢ PWDT ā¢ CORE ā¢ PRIME ā¢ FARM ā¢ Documentation of Pharmaceutical care process
- 2. 12/28/2012 2 New Trends in Monitoring & Managing Patient Care ā¢ Pharmacist responsibility to reduce drug related problems has lead to the concept of pharmaceutical care ā¢ Reduces the possibility of drug related problems & enhances the quality of life ā¢ Pharmaceutical care helps in achieving definite outcome in health care: ā Curing the disease ā Reducing or eliminating symptoms ā Arresting or slowing the disease process ā Preventing the disease or its symptoms New Trends in Monitoring & Managing Patient Care contā¦. ā¢ Monitoring drug therapy and out come is important for providing pharmaceutical care. It includes: āIdentifying actual or potential drug related problems āResolving the actual drug related problems āPreventing the potential drug related problems
- 3. 12/28/2012 3 Pharmaceutical Care ā¢ Pharmaceutical care describes specific activities and services through which the individual pharmacist ā co-operate with the patient and other professionals in designing, Implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient.ā Pharmaceutical Care ROLE: Pharmaceutical care has evolved from an emphasis on prevention of drug- related problem Function: ā¢ It does not imply that the pharmacist is no longer responsible for dispensing function. ā¢ Rather redesign of professional work flow, with assignment of technical functions to technical personnel under the direct supervision and responsibility of the Pharmacist.
- 4. 12/28/2012 4 Traditional Pharmacy Clinical Pharmacy Pharmaceutical Care Primary Focus Prescription order and OTC order Physician or other health professionals Patient Continuity Upon demand Discontinuous Continuous Strategy Obey Find fault or prevention Anticipate or improve Orientation Drug product Process Outcomes Uniqueness Of Pharmaceutical Care Essential Components of Pharmaceutical Care Pharmacist work up of drug therapy (PWDT)
- 5. 12/28/2012 5 EPharmacist work up of drug therapy (PWDT)WDT 1. Data Collection 2. Develop or identify the CORE pharmacotherapy 3. Identify the PRIME pharmacotherapy problems 4. Formulate a FARM progress note Data Collection Collects, synthesize, interpret relevant information, such as: (a) Patient demographic data: age, race, sex (b) Patient medical information (i) Current and past medical history (ii) Family history (iii) Social history (iv) Dietary history
- 6. 12/28/2012 6 1- Data Collection Contā¦ā¦ (v) Medication history (prescription, OTC, social drugs, allergies) (vi) Physical findings( weight, height, blood pressure, edema) (vii) Laboratory or other test result (eg: serum drug level, potassium level, serum creatinine as relevant to drug therapy) (viii) Patient complaints, symptoms, signs Data Collection Develop or identify the CORE pharmacotherapy Develop or identify C=Conditionor patient need O=outcomesdesired for that condition (Patient&Therapeuticend point) R= Regimen selected to achieve that outcome 1. Therapy regimens: Existing therapy & initial therapy) 2. Goal setting & behavior regimens: E= Evaluation parameters to assess outcome achievement 1. Efficacyparameters 2. Toxicity Parameters
- 7. 12/28/2012 7 3Identify the PRIME Pharmacotherapy problems The goal of PRIME is to identify actual or potential problems that could compromise the desired patient outcomes. P= Pharmaceutical based problems R= Risk to patient I= Interaction M=Mismatch b/w medications and condition or patient needs E= Efficacy issues 3-PRIME pharmacotherapy problems Contā¦. P = Pharmaceutical ā¦ā¦.asses for incorrect * dose *form *monitoring * route *timing *duration *frequency R= Risks to patient ā¦ā¦..assess for * known contraindications * patient medication allergy * drug-induced problems * improper utilization * common/serious adverse effects * medication error considerations
- 8. 12/28/2012 8 3-PRIME pharmacotherapy problems Contā¦. I=Interaction ā¦ā¦.assess for *drug-drug *drug-disease *drug-food *drug-lab M=Mismatch ā¦.assess for *Medications used without indication * indication, condition, or complaint untreated * Actual barriers to implementation of medication or behavior regimens 3-PRIME pharmacotherapy problems Contā¦. E = Efficacy issues ā¦ā¦assess for *suboptimal selection of pharmacotherapy for indication * too much correct drug * minimal or no evidence of therapeutic effectiveness * suboptimal utilization of pharmacotherapy * patient preference considerations (e.g. undesirable prior experiences with medication, does not believe it works) * medication availability considerations * compliance or administration considerations ( e.g inability to pay, unable to administer correctly or at all)
- 9. 12/28/2012 9 Formulate a FARM progress note FARM progress notes to describe and document the interventions intended or provided by the pharmacist. 4- FARM progress note contā¦ F=Findings: the patient specific information that gives a basis for, or leads to, the recognitionof a pharmacotherapy problem or indication for pharmacist intervention. A=Assessment: the pharmacistās evaluation of findings, including a statement (i) any additional informationneeded to assess the problem (ii) severity, priority or urgency of the problem (iii) short term and long term goals of the intervention Formulate a FARM progress note
- 10. 12/28/2012 10 4- FARM progress note contā¦ R=Resolution (including prevention): the interventionplan includes actual or proposed actions by the pharmacist. The interventionoptions may include: *counselingor educating the patient * making recommendationsto the patient and caregiver * informing the prescribers * making recommendationsto the prescribers * withholding medication or advising against use Formulate a FARM progress note 4- FARM progress note contā¦ M=Monitoring and follow up: the parameters and timing of follow up monitoring to assess the efficacy, safety and out come of the intervention. It includes: (i) parameters to be followed (ii) intent of the monitoring (iii) ways of monitoring the parameters (iv) frequency of monitoring (v) duration of monitoring (vi) anticipated or desired finding (vii) decision point to alter the therapy Formulate a FARM progress note
- 11. 12/28/2012 11 Managerial skills ā¢ Plan ā¢ Direct ā¢ & Implement pharmaceutical care activities within various practicing environments, such as community pharmacy, ambulatory care settings, home health services, inpatient hospital practice and others. Formulate a FARM progress note WORKUP OF DRUGWORKUP OF DRUG THERAPY INTHERAPY IN PHARMACEUTICAL CAREPHARMACEUTICAL CARE Patient name: ____________________ Date: ____________________ Case: ____________________ Pharmacist: ____________________ Problem Oriented Pharmacist Record
- 12. 12/28/2012 12 PATIENT DATABASE1 A. Patient Description Name: ________________ Age: ____________years Reg. no: ________________ Sex: ________________ Weight: ________________ Admission: ______________ Race: _____________ Height: ______________ B. Chief Complaint (CC) ___________________________________________ _______________________________________________________________________ _______________________________________________________________________ C. History Of Present Illness (HPI) __________________________________ _________________________________________________________________________________ _____________________________________________________________ D. Past MedicalHistory (PMHx) PrescriptionResolveOnsetDisease E. Compliance Good ļ£ Moderate ļ£ Poor ļ£ Comments: __________________________________________________________________ F. Histories Of Allergies Yes ļ£ No ļ£ Not known ļ£ Type: _________________________________________________________________________ G. Social History (Soc. Hx) Smoking: Yes ļ£ No ļ£ Not known ļ£ Alcohol: Yes ļ£ No ļ£ Not known ļ£ H. Medication History 1. Is the patient currently or within the past three months taking medication(s) which require a prescription? Yes ļ£ No ļ£ , if yes please identify, list and describe (including drug, dose, regimen, duration and use) _______________________________________________________________________________________ _______________________________________________________________________________________ 2. Is the patient currently taking OTC medication(s)? Yes ļ£ No ļ£ , if yes please identify, list and describe (including drug, dose, regimen, duration and use) _______________________________________________________________________________________ _______________________________________________________________________________________ 3. Medication history assessment: Patient non compliance _______________________________________________________________ Inadequate medication knowledge _______________________________________________________ Inappropriate medication use ___________________________________________________________ Inadequate communication with health professional _________________________________________ ADR ______________________________________________________________________________ Other medication related problems ______________________________________________________ I. Pharmacologic Review Of System Comment: EENT: Fluidstatus: Neuro/Mental: Skin/Muscle: ABDO: BLOOD: CHEST: CVS: Hepatic: KUT: VS: General status:
- 13. 12/28/2012 13 J. Laboratory X-Ray2HPP/INS ECGBUN/Ser ONC/MAPPLTS CO/ClEOS/BSO PAS/PADLYM/MNO PWP/CVPPMN/BND CI/AOOHHgb/HCT AA/GLUWBC/RBC WTPEEP/CPAP I/ORR/Vent HR/Temp(maxPO2 / % BP:S/DpCO2 / HCO3 -1 TT / FDPpH / Osat PT /aPPTAl/ TP BLI/APstMg/UA CPK/MBESR AMY/LDHCa+2/PO4 -2 SGOT/GGTCl-1/HCOĀĀĀ3 -1 FBS/RBSNa+/K DateDate Sensitivit y IsolateSourceDateDose changeSCon.DrugDate Others:___________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ K. Diagnosis / Provisional Dx / Medical Problem List ___________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________
- 14. 12/28/2012 14 L. Drug Treatment In Ward Comments Othe rs `Cos t Dura tion Drug Dupl icati on Drug - Dise ase Inter actio n Dru g- Dru g Inter actio n Dire ctio n Dosag e Effec tiven ess Indic ation StopStartDrug regimen Assessment Factors: 1 => Indicated, Effective, Correct, Practical, Insignificant, Necessary, Acceptable, Least expensive 2 => Not Indicated, Ineffective, Incorrect, Impractical, Significant, Unnecessary, Unacceptable, Most expensive 3 => Donāt know (unable to assess) 2 PATIENT SPECIFIC, DRUG RELATED PROBLEM LIST Category 1: Medical Indication For A Drug Category 2: too little of the correct drug Category 3: too much of correct drug A new medical problem requiring a drug therapy: ______________________________________ ______________________________________________________________________________ Continuity of a drug therapy: _______________________________________________________ _______________________________________________________________________________ Prophylaxis or premedication: ______________________________________________________ _______________________________________________________________________________ Synergism or potentiation (desired combination Rx): ____________________________________ _______________________________________________________________________________ Others: ________________________________________________________________________ Dose too low (wrong dose error): ___________________________________________________ Sub therapeutic drug concentration: __________________________________________________ Timing prophylaxis (too early, presurgical, antibiotics): __________________________________ Drug, route, dosage form, formulation, conversion, deteriorated drug: _______________________ Monitoring error: ________________________________________________________________ Others:_________________________________________________________________________ Dose too high (wrong dose error/extra dose error): _____________________________________ Toxic drug concentration: _________________________________________________________ Too-rapid dose escalation/ wrong rate or administration: _________________________________ Dose- accumulation: _____________________________________________________________ Drug, route, dosage form, formulation, conversion problem: ______________________________ Dose and interval flexibility miscued (wrong time): _____________________________________ Monitoring error: ________________________________________________________________ Others: ________________________________________________________________________
- 15. 12/28/2012 15 Category 4: wrong drug Category 5: problem secondary to an ADR Category 6: drug-drug, drug-food, drug-laboratorytest interaction Drug not effective for indication: ____________________________________________________ Allergies to medication: ___________________________________________________________ Not the most effective: ____________________________________________________________ Contraindication: ________________________________________________________________ Effective, yet not the most economical choice: _________________________________________ Effective, yet not the safest pharmacotherapy: _________________________________________ Resistant organism: ______________________________________________________________ Refractory to present drug: _________________________________________________________ Unnecessary drug combination when single drug is appropriate: ___________________________ Monitoring error: ________________________________________________________________ Others: ________________________________________________________________________ Drug administration problem (too rapid): ________________________________ Prescribing issue (allergic reaction): ____________________________________ Patient risk factors: _________________________________________________ Idiosyncratic reaction: _______________________________________________ Monitoring error: ___________________________________________________ Others: ___________________________________________________________ Drug food: _____________________________________________________________________ Physical interaction (reduce bioavailability): ___________________________________________ Increase or inhibit excretion: _______________________________________________________ Enzyme induction/inhibition: _______________________________________________________ Decreased absorption of one of the drugs: _____________________________________________ Displacement from binding sites: ____________________________________________________ Laboratory test interference: _______________________________________________________ Synergism or potentiation: _________________________________________________________ Others: ________________________________________________________________________ Category 7: problem due to patient not receiving drug Category 8: no valid medical indication Category 9: miscellaneous Medications errors (omission error), medication knowledge: ______________________________ Patient Non-compliance: ___________________________________________________________ Socio-Economics: ________________________________________________________________ Patient Health beliefs/Satisfaction: __________________________________________________ Others: ________________________________________________________________________ Drug abuse: ____________________________________________________________________ Unapproved indication: ___________________________________________________________ Polypharmacy: __________________________________________________________________ Inappropriate use of OTC: _________________________________________________________ Unauthorized drug error: __________________________________________________________ Others: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
- 16. 12/28/2012 16 3 DESIRED PHARMACOTHERAPEUTIC OUTCOMES FOR EACH DRUG-RELATED PROBLEM i. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ii ._________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ iii._________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ iv._________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ v. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ vi._________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ vii.________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ viii.________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ix._________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 4 FEASIBLE PHARMACOTHERAPEUTIC ALTERNATIVES FOR EACH DRUG-RELATED PROBLEM CommentsSupply Interact ion Predicta bility CostSafety Dosage Practica lity Efficacy Alternatives (drug, dose, dosage form, frequency, route and duration) 1 => Effective, Practical, Safe, Least expensive, Predictable, Insignificant, Standard drug 2 => unapproved, least practical, more toxic, expensive, unpredictable, Significant, special request 3 => Donāt know (not enough data to evaluate)
- 17. 12/28/2012 17 5 CHOOSE THE āBESTā PHARMACOTHERAPEUTIC SOLUTION AND INDIVIDUALIZE THE THERAPEUTIC REGIMEN 6 THERAPEUTIC DRUG-MONITORING PLAN i.__________________________________________________________________________________ ii.__________________________________________________________________________________ iii.__________________________________________________________________________________ iv._________________________________________________________________________________ v.__________________________________________________________________________________ vi. _________________________________________________________________________________ vii. _________________________________________________________________________________ viii. ________________________________________________________________________________ ix.__________________________________________________________________________________ i.__________________________________________________________________________________ ii.__________________________________________________________________________________ iii.__________________________________________________________________________________ iv._________________________________________________________________________________ v._________________________________________________________________________________ vi.__________________________________________________________________________________ vii._________________________________________________________________________________ viii._________________________________________________________________________________ ix.__________________________________________________________________________________ 7 IMPLEMENT THE INDIVIDUALIZED REGIMEN AND MONITORING PLAN (viii) (vii) (vi) (v) (iv) (iii) (ii) (i) Comments Acceptance Code PharmaceuticalCare Recommendation (Communication) Acceptance code: Y = Yes, recommendation accepted, N = recommendation rejected. C = Yes, recommendation accepted but with changes
- 18. 12/28/2012 18 8 FOLLOW UP Subjective, Objective, Assessment and new DPR, Plan (SOAP)Date 9 DISCHARGE SUMMARY AND COMMUNICATION A. SUMMARY ________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ B. COMMUNICATION ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________
- 19. 12/28/2012 19 Data Collection 1-Review patient medical record 2-Review medication profile 3-Interview patient Develop or identified the CORE Pharmacotherapy plan Identify the drug related problems or patient needs PRIME Formulate a pharmaceutical care plan Communicate plan with patient health care team Document actions taken in patient medical record Follow Up Thank you