Pharmacy Practice , Pharm.

D Balsam AlHasan

PHARMACEUTICAL CARE PROCESS

THE PHARMACEUTICAL CARE PROCESS

The delivery of effective pharmaceutical care to patients requires pharmacists to practice

in a way that uses their time effectively and

reflects their responsibility and accountability.

 Ideally

all patients who receive

pharmaceutical products or services

should also receive pharmaceutical

care.

CARE PLAN STEPS:

PHARMACEUTICAL CARE
Pharmacists should assume that all patients require pharmaceutical care until they have been assessed to exclude drug therapy problems (Step 1). However, due to limited resources, this step is not always possible and a systematic approach (Figure Above) may need to be adopted to facilitate the targeting of care.

PHARMACEUTICAL CARE

Prioritization is used routinely in health care,

especially in resource-constrained
environments, to ensure that services are

targeted particularly to those patient groups and

individual patients who need them most. Targeting may occur prior to Step 1 or as part of Step 1 depending on available resources.

STEP 1:
Assess the patients drug-therapy needs and identify actual and potential drug therapy problems:

Good communication needs to be established with the patient, care giver and other members of the health care team at the outset in order for pharmacists to collect, synthesize and interpret the relevant information.

STEP 1:

When pharmacists assess patients, they must take full account of all patient and medication factors that may predispose patients to the risk of drug therapy problems. The assessment process involves talking to patients, care givers or representatives and consulting other members of the health care team, as well as reviewing patient medication and clinical records.

STEP 1:

Although the focus is on drug therapy problems, the process allows the identification of disease-related problems as the therapeutic approach is verified and validated. In addition, opportunities for health promotion and preventive health care are identified and incorporated within the plan.

PHARMACEUTICAL CASE STUDY

EXAMPLE: CASE STUDY 1:

Mrs W, a 53-year-old woman has had gastrointestinal acid-related disorders (GERD) diagnosed by endoscopy. Mrs W has a history of asthma, hypertension and duodenal ulcer (DU). Her current drug therapy includes: amlodipine (10mg in the morning), salbutamol inhaler (two puffs as required), beclometasone inhaler (200mcg twice daily), and theophylline (300mg twice daily).

Mrs W has recently undergone successful H. pylori eradication therapy, which has been confirmed by carbon urea breath test. Mrs W smokes 10 cigarettes a day, has a body mass index of 35 and does not drink alcohol

IDENTIFY LIFESTYLE, MEDICINE AND DISEASE FACTORS FOR THE ABOVE PATIENT:

1.

Lifestyle factors:
She is obese and should try to lose weight.
She is a smoker. Nicotine can cause reflux by reducing lower oesophageal sphincter tone.

Other factors may exist but are not apparent from the history. For example, she does not drink alcohol but may drink an excess of coffee or other beverages such as colas or tea, which would exacerbate GERD due to their caffeine content.

2. DRUG FACTORS

Calcium channel blockers reduce lower oesophageal sphincter tone which can lead to acid reflux. Perhaps the amlodipine could be changed to another anti-hypertensive such as bendroflumethiazide (bendrofluazide).

Theophylline also reduces lower oesophageal sphincter tone. Review asthma management. If appropriate, could stop theophylline without adding on therapy or replace theophylline with another drug such as salmeterol.

3. DISEASE FACTORS

Diagnosis of GERD may have been masked by long term treatment of DU which has recently been healed by H. pylori eradication; this is not uncommon.

Atypical presentations of GERD include asthma symptoms linked to acid reflux.

TYPES OF DRUG-RELATED PROBLEMS

TYPES OF DRUG-RELATED PROBLEMS

Needing pharmacotherapy and not receiving it (a drug indication).

Taking or receiving the wrong drug. Taking or receiving too little of the correct drug.

Taking or receiving too much of the correct drug. Experiencing an adverse drug reaction. Experiencing a drug-drug or drug-food interaction.

Not taking or receiving the drug prescribed. Taking or receiving a drug for no valid indication.

COMMUNITY PHARMACY:

Self-care (where patients purchase medicines over the counter) is an important component of all health care systems. Unfortunately it may be the only form of access to medicines in countries unable to sustain a publicly-funded health service.

It is just as important for pharmacists to provide pharmaceutical care for such patients who may be at greater risk of drug therapy problems due to limited medical supervision of therapy.

STEP 2:

Develop a care plan to resolve and/or prevent drug therapy problems:

Not all patients may progress to Step 2. For example, no problems may have been identified at Step 1 or you may not be able to meet the needs of

a particular patient due to severe resource

limitations.

STEP 2:

If the latter is the reason the drug therapy problems identified should be documented and brought to the attention of the patient and the health care team and advice provided for reasons of ethical, clinical and professional

responsibility, even if the patient cannot be

followed up.

 PRIORITIZE DRUG THERAPY PROBLEMS:

Once identified (Step 1), drug therapy

problems should be prioritized within the context of the overall clinical management of

the patient.

IDENTIFY DESIRED THERAPEUTIC OBJECTIVES AND PROPOSED ACTIONS

A statement should be made of what the pharmacist intends to achieve for a patient in relation to each drug therapy problem. The statements should be agreed with the patient and the health care team.

These therapeutic objectives should be expressed as measurable outcomes to be achieved within a defined time scale. In deciding on the most appropriate actions it is vital that the pharmacist confirms the acceptability of these actions with the patient.

If a number of options exist, the patient must be given sufficient information to select the most appropriate option.

 DEVELOP A MONITORING STRATEGY:

A monitoring strategy should be identified to

measure progress towards achievement of the

therapeutic objectives. This strategy should be

agreed with the patient and other members of

the health care team and should be undertaken at specified intervals and for a defined period prior to further review.

 DOCUMENT THE CARE PLAN :

The pharmacists record of drug therapy problems and therapeutic objectives, together with the proposed actions, form a documented pharmaceutical care plan. Good documentation facilitates continuity of care and clinical audit.

CASE STUDY EXAMPLE 2:

Mr D, aged 52 years, has been diagnosed with hyperlipidaemia and advised on diet and lifestyle measures for the past year. His medical history includes hypertension and atrial fibrillation (AF). His blood pressure was recently measured as 140/85 mm Hg, pulse 40 beats per minute and a lipid screen showed total cholesterol of 8.4 mmol/L.

On interview the patient complains of tiredness and weight gain. Current drug therapy is as follows: amiodarone 200 mcg in the morning bendroflumethiazide 10 mg in the morning

STEP 3:

Implement the care plan:

The pharmaceutical care plan is implemented with the agreement of the patient and, where possible, within the context of the overall care of the patient, in cooperation with other members of the health care team.

CASE STUDY EXAMPLE 3:

Mrs J, aged 45 years, has recently been diagnosed with asthma, following reversibility testing with a short-acting bronchodilator. Her relevant medical history includes osteoarthritis and hypertension. Her blood pressure was recently measured as 170/ 110 mmHg. Mrs J smokes 30 cigarettes a day, is a moderate to heavy drinker and does no physical exercise.

Previous drug therapy of bendroflumethiazide 2.5 mg in the morning was ineffective for hypertension. Her current drug therapy is as follows: Paracetamol 500 mg 2 as required up to 8 in 24 hours Propranolol 40 mg three times daily Salbutamol metered dose inhaler (MDI) 2 puffs as required Budesonide turbo (dry powder inhaler) 200 mcg twice daily

STEP 4:

Evaluate and review the care plan:

Actual outcomes are evaluated in relation to the therapeutic objectives to determine whether drug therapy problems have been resolved. If outcomes are not achieved, the care plan should be reviewed.

The actual outcomes may then be accepted as being the best achievable for the patient, or an alternative plan may be necessary. The plan should develop as original drug therapy problems resolve and new drug therapy problems appear, which require resolution.

CASE STUDY EXAMPLE 4:

For

the same earlier patient

QUESTIONS??