??????:????????? Pharmacy Practice Skills: Drug-Related Problems Solving

1
???????????????Pharmacy Practice Skills
Drug-Related Problems Solving

2
????

• ?? systematic clinical drug monitoring ???????
• ?? SOAPing format ??????????????
• ?? patient case presentation ??????
• ??? SOAPing format ???????????
• ?????,?????????????
• -???????,????

3
Systematic Clinical Drug Monitoring????

• The responsibility of a pharmacist to provide
  services in a consistent and complete manner
• The complexity of a patients health problems
• The comprehensible communication among health
  care professionals

4
The Purposes of Systematic Clinical Drug
Monitoring

• Determine that all of a patients drug therapy is
  the most appropriate, most effective, safest, and
  most convenient available.
• Identify any drug therapy problems (DTPs DRPs)
  and the goal of therapy.
• Identify any drug therapy problems (DTPs) the
  patient is at risk of developing in the future?
  that is to say, any drug therapy problems the
  pharmacist must help the patient to prevent in
  the future

5
Pharmaceutical Care Process
6
Problem-Oriented Approach

• In 1964, Lawrence E Weed published the
  problem-oriented approach to medical records,
  patient care, and medical education.
• A systematic, disciplined approach to each
  patient is used
• No important therapeutic considerations are
  missed

7
Problem-Oriented Approach

• Two main components
• Complete problem list
• Physical
• Psychological
• Social/financial
• SOAP notes
• Logical thinking process
• ???????, ????????
• One visit one SOAP

8
POMRProblem Oriented Medical Record

• Dr. Lawrence Weed ???????????
• POMR Problem List (? x ?) ?? SOAP
• Problem 1 SOAP 1
• Problem 2 SOAP 2
• Modified SOAP
• S
• O
• A (Problem 1, 2, )
• P (Problem 1, 2, )

9
????

• ????
• ???????
• Patient Case Presentation
• From database to plan
• 1. From data base to assessment (SOAP notes)
• 2. Assessment
• 3. From assessment to plan (Implentation)
• SOAPing format
• ????
• Daily SOAP note
• Oral case presentation

10
??????
11
????????-????

• ????
• ?????-????
• ??????(????, ??, ??, workbook,
  pharmacotherapy?????)
• Disease Management Case Demo (ASHPs PharmPrep
  2001)
• Terry L. Schwinghammer pharmacotherapy Casebook
  6th Ed.
• ????
• ???? (10????)
• ?????,????
• 1. ???? 2??
• 2. ???? 1??
• 3. ?????? SOAPing format???
• (2??/?, ? 5-6?)

12
???????
13
???????

• ??
• ????
• ????
• ????

14
????

• ???? (Discharge summary)
• ??? (?? / ?? -TPN ? C/T)
• TPR sheet
• Admission note (????? / ??????????)
• Progress note (SOAP format)
• ????
• ????? (X-ray, Cath, RT)
• ???? (Lab data)
• ??????? (GCS, APACHE II scale)
• ??????? / ???????
• ????
• ????
• ?????/ ????
• ?????? ????? / ???????

15
Medication Administration Record(MAR)

• Routine or maitenance
• Antibiotics, anticonvulsants
• P.R.N.
• Usually are listed at the end of the MAR
• Fever (if gt38.5?)
• Pain medication
• Antiemetics
• Sedative-hypnotic agents
• Stat (Statim, immediately)
• Administered once and not repeated unless
  recorded
• Given as soon as possible
• Prescribed in life-threatening or emergency
  situations
• One time order
• Given as soon as convenient and sometimes can be
  scheduled ahead of time
• C/T

16
???? Progress Note

• ??
• ?????????????????????
• ??-????, ??(??), ????, ??????
• ???
• ????????,?????,?????,?????????????
• ?????,??????,??????????
• ?????,??????????,???????????????????????
• ?????,????????,??????????,??????????
• ?????,??????????,?????????
• ??-SOAP format

17
????

• ??????(????)
• ????
• ??????
• ????

18
???? (??)

• ???????? (??? ??)
• ??????
• ?, ?, ?, ?, ??, ??
• ????, ????, ??, ????
• ???????????? (??? ??)
• ?????? (primary care training)
• ?? (??????, ????????????)
• ?? (CV, GI, Nephro, Chest, Endo, Neuro, Rheuma,
• ID, Hema, Oncology)
• The Washington Manual of Medical Therapeutics
  31ed.
• Clinical skills for pharmacists, A
  patient-focused approach. 2nd Ed. Karen J.
  Tietze, Mosby

19

• Patient Case Presentation

The accepted tool for documenting and
communicating patient information (suggested by
Tietze, K.J.)
20
Components of the Patient Case Presentation

• General information
• Chief complaint (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Medication history (MedHx)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)
• Physical examination (PE)

• Pertinent positive and negative laboratory and
  diagnostic test results (Labs)
• Pt problem list and initial plans
• Pt progress
• Discharge data
• Final diagnosis
• Discharge medications
• Plans for follow-up

21
Suggested Sequence for Presentation of Information

• ?
• Review of systems (ROS)
• ?
• Physical examination (PE)
• ?
• Laboratory and diagnostic test results (Lab)
• ?
• Problem list and initial plans
• (SOAP format)
• ?
• Pt progress to date
• (SOAP format)

• General information (Gen)
• ?
• Chief complaint (CC)
• ?
• History of present illness (HPI)
• ?
• Past medical history (PMH)
• ?
• Social history (SH)
• ?
• Family history (FH)
• ?
• Medication history (MedHx)
• ?

22
From database to plan
Steps of Systematic Clinical Drug
Monitoring (suggested by Shao C, Chiang,
Pharm.D., R.Ph.)
23
Problem Conversion

• Medical problems (Dx)
• Medication problems
• (Drug therapy problems )

24
From Database to Plan

• 1.From data base to assessment
• SOAP notes
• 2.Assessment
• 3.From assessment to plan (Implentation)
• Therapeutics planning-pharmacist
• Diagnostic
• Therapeutic (Prescription)
• Educational (pt)
• Monitoring

25
1.From data base to assessment (SOAP notes)
At admission (new pt)
26
SOAPing
Database
CC HPI PMH FH SH Med Hx Compliance Allergies ROS PE Lab tests X-ray Scans Procedure SOAP notes
Problem list
numbered acuity/priority Resolved / inactive
SOAP notes
Implementation of plan
diagnostic therapeutic educational (pt)
Follow-up of progress
27
2. Assessment
At admission (new pt)
28
Interpret the Findings in Terms of the Probable
Process

• Pathological process
• Congenital / Inflammatory
• Immunological / Neoplastic
• Metabolic / Nutritional
• Degenerative / Vascular
• Traumatic / Toxic
• Pathophysiological
• Psychopathophysiological
• Drug-related

29
Make One or More Hypotheses about the Nature of
the Patients Problem

• Select the most specific and central findings
  around which to construct your hypothesis.
• Match your findings against all the conditions
  you know that can produce them.
• Eliminate the diagnostic possibilities that fail
  to explain the findings.
• Weigh the competing possibilities and select the
  most likely diagnosis from among the conditions
  that might be responsible for the patients
  findings
• Give special attention to potentially
  life-threatening and treatable conditions

30
3.From assessment to plan (Implentation)
Therapeutics planning
At admission (new pt)
31
Components of Therapeutics Planning
Regimens- initial alternative
32
The Planning Process

• Problem identification
• Identification of subjective and objective
  parameters
• Grouping of related parameters
• Assessment of the parameters and determination of
  specific pt problems
• Problem prioritization Identify active and acute
  problems
• Selection of specific therapeutic regimens
• Creation of a list of therapeutic options
• Elimination of drugs from the list based on
  pt-specific and external factors
• Selection of dosage, route, and duration of
  therapy
• Identification of alternative therapeutic
  regimens
• Creation of a monitoring plan
• Monitoring and modification of the regimens as
  necessary

33
Common Subjective Parameters
Anxiety Bloating Blood-tinged sputum Blurred vision Breast tenderness Chills Cold intolerance Confusion Constipation Cramps Decreased appetite Depression Diarrhea Difficulty concentrating Dry skin Dysuria Fatigue Flatulence Headache Heartburn Heat intolerance Impotence Indigestion Insomnia Itching Joint pain Loss of appetite Loss of libido Muscle aches Muscle weakness Nasal congestion Nasal itching Nausea Nervousness Numbness Pain Palpitations Pounding pulse Rash Seizures Shortness of breath Slurred speech Sneezing Sore throat Syncope Thirst Tingling Tinnitus Tremor Vertigo Weakness Wheezing
34
Common Objective Parameters
BH and BW Vital signs BT, BP, HR, RR Blood chemistries Na, K , Cl, CO2, Glu, Scr, AST, ALT, Bil, Ca, Mg, CHL, TG, Alk-P, LDH, UA, BUN Blood gases pH, Pco2, Pco2, HCO3- Blood protein Total protein, albumin, complements, immunoglobulins Hematolog Hb, Hct, MCV, MCH, MCHC, RBC, WBC DC Urinalysis Sp. gr, cellular content, protein Cultures and sensitivites Blood, urine, sputum, tissue Serum blood concentrations Specific organ system tests PEFR, FEV1, FVC , FEV1/FVC, EF, T3, T4, TSH, Clcr Miscellaneous U/O, abd girth, no. of loose stools/day, I/O
35
Factors to Consider when Selecting a Specific
Therapeutic Regimen

• Patient-specific factors
• What regimens have effectively managed the
  problem in the past?
• What regimens have not effectively managed the
  problem in the past?
• How might other patient problems influence the
  proposed regimen?
• How might the proposed regimen influence other
  patient problems?
• External factors
• Current state of the art therapeutics
• Cost of the proposed therapv
• Formulary limitations

36
Guidelines for Altering Initial Drug Therapy

• If the regimen is ineffective, change the drug if
  the following are true
• The patient received an adequate trial of the
  drug
• The patient received an adequate dosage of the
  drug
• The patient is compliant
• If the regimen is associated with
  life-threatening side effects, discontinue the
  drug
• If the patient is not complying with regimen
  because of unacceptable side effects, discontinue
  the drug
• If the patient has non-life-threatening side
  effects and is willing to continue the drug,
• minimize the side effects by doing the following
• Adjust the dosage of the drug
• Change the timing of the dose

37
3.From assessment to plan (Implentation)
Monitoring
At admission (new pt)
38
Patient-Focused Care Cycle A Never-Ending Cycle

39
The Process of Monitoring Therapeutic Regimens

1. Set therapeutic goals
2. Determine patient- and drug-specific monitoring
   parameters
3. Integrate the monitoring plan
4. Obtain data
5. Assess the response to therapy
6. Alter the therapeutic regimen if necessary
7. Repeat Step 1-6

40
Organization of Monitoring Parameters (The
Four-Square Method)
Subjective-Therapeutic Subjective-Toxic
expected therapeutic outcome indicating therapeutic failure or harm
Objective-Therapeutic Objective-Toxic
expected therapeutic outcome indicating therapeutic failure or harm
41
Steps of systematic clinical drug monitoring at
inpatient setting
Hospital stay (old pt)
42
Hospital Stay

• Daily SOAP note
• Each problem has its own SOAP note.
• The subjective and objective data should include
  the values of drug monitoring parameters.
• All problems should be assessed and planed,
  unless the problem has been resolved
• Daily drug monitoring

43
Real Practice Setting

• With time and practice, the process of assessing
  patient therapy and prioritizing the need to make
  an intervention becomes second nature and does
  not require a concerted effort to mentally check
  off each step after it has been performed.
• Setting priority about which patients require
  more in-depth intervention.

44
SOAPing format
45
SOAPing Format

• SOAPing
• The process of identifying the subjective and
  objective data, assessing the problem, and
  developing a specific therapeutic and monitoring
  plan
• A formal organizationl structure
• Steps
• Creation of a list of related subjective
  parameters
• Creation of a list of related objective
  parameters
• Assessment and documentation of the problem
• Documentation of the therapeutic plan for
  addressing the problem

46
Thinking Process Tips

• Problem identification
• Desired outcome
• Therapeutic alternatives
• Optimal plan
• Outcome evaluation
• Patient education

47
Problem List
Current medical problems Goal of therapy Measurable endpoint




48
SOAPing FormatUSC School of Pharmacy Kathleen
Besinque Pharm D, MS Ed.)
49
Current Drug-Therapy Problems
Subjective and Objective Subjective and Objective
Problem(subjective and objective) Current medication
S CC Pertinent medical Hx(HPI / PMH) ROS SH FH Allergies ADR Drugs OTCs Herbal
O (PE /Labs) Drugs OTCs Herbal
50
Current Drug-Therapy Problems
Assessment Assessment
Etiology (or risk factors) Evaluate need for therapy evaluate current therapy (Evidence need for therapy evaluation)
Drug therapy problem 1 CPG1 Class of drugs
Drug therapy problem 2 CPG2 Class of drugs
Drug therapy problem 3 CGP3 Class of drugs
51
Current Drug-Therapy Problems
Plan Plan Plan
Recommended drug treatment, drug to be revised, further test Goal and monitoring parameters (toxic and therapeutic) Patient education
Recommend 1 Item of drugs Goal 1 Therapeutic Toxic Education 1
Recommend 2 Item of drugs Goal 2 Therapeutic Toxic Education 2
Recommend 3 Item of drugs Goal 3 Therapeutic Toxic Education 3
52
Problem Conversion

• Medical problems (Dx)
• Medication problems
• (Drug therapy problems)

53
???????????
54
??????????? (1)

• ???? clinical drug monitoring ? case presentation
  ??????
• ??????????????????
• ??????? (????)????????
• Medical problem (Dx) Medication problems
• 
  (Drug therapy problems)
• ?????????????daily SOAP note
• ????????
• ???????????

55
??????????? (2)

• ????????????????
• ????????????????
• ???????
• ???????????
• ?????????Drug therapy problems
• ??????
• ?????????, ????Drug therapy problems???
• ???????? / ??????????
• ????? concurrent case
• ????????
• ???????????
• ???????????????????????

56
??

• Problem oriented drug monitoring
• ????????
• ??????Drug therapy problems
• ??????????
• ?????????
• ????/???????-???

57
Case Example(????)Hypertension
58
????(HTN)

• Establish goals for the treatment of HTN.
• Choose appropriate lifestyle modifications and
  anti-HTN based on patient-specific characteristis
  and concurrent disease states.
• Design appropriate monitoring plans for pts
  receiving anti-HTN therapy, including laboratory
  parameters and time intervals.
• Modify pharmacotherapeutic regimens for pts who
  experience adverse events or do not have adequate
  BP reduction on an initial regimen.
• Provide appropriate patient education for
  anti-HTN regimens.

59
Patient General Information (Gen)??????
Patient name ??? Patient name ???
Chart no xxxxxxxx (Bed no xxxx-x) Chart no xxxxxxxx (Bed no xxxx-x)
Address ?????? Address ??????
Age 79 Height 175 cm
Sex M Marriage status married
Weight 95.4kg Allergies NKDA
Date of admission (DOA) yy mm dd Date of admission (DOA) yy mm dd
60
Chief Complaint (CC)??????

• ??? is 79-yo male seen in the ED with respiratory
  distress with severe dyspnea and wheezing.

61
History of Present Illness (HPI)?????????

• ??? was coming home from the grocery store when
  he became short of breath and wheezing carrying
  in his groceries.
• He could only say a couple words between breaths.
  His neighbor noticed him in distress and called
  911.
• ??? experienced severe shortness of breath 6
  months ago and was hospitalized for acute severe
  asthma.

62
Past Medical History (PMH)????

• Diagnosis with asthma approximately 20 years ago,
  rheumatoid arthritis about 5 years ago, and
  benign prostatic hyperplasia last year.
• Patient using a herbal product to treat his
  benign prostatic hyperplasia.
• Admitted to hospital 3 times in the past 2 years
  for exacerbation of asthma.
• Previous office visit 5 weeks ago, documented a
  blood pressure reading of 150/95 mmHg.

63
Social History (SH)?????

• Tobacco use 1/2 pack/week
• Alcohol use Six pack per week
• Caffeine use 2 Cups of coffee every morning

64
Family History (FH)????

• Mother died of an MI at age 68.
• Father died of lung cancer at age 75.

65
Medication Record (Prescription and OTC)
(MedHx)???

• Furosemide 40 mg po q AM
• Albuterol inhaler 2 puffs qid prn
• Beclomethasone inhaler 1 puff qid
• Ibuprofen 800 mg po tid
• Herbal product with licorice po qd
• Acetaminophen po prn

66
Review of Systems (ROS)??????? (HPI ??)

• Wheezing and coughing

67
Physical Examination (PE)????

• VS
• BP 160/100 mmHg
• HR 120 beats/min
• RR 31 rpm
• T 38.5?
• Ht 175 cm
• BW 95.4 kg
• BMI 31.2 (95.4/1.75x1.75)
• CHEST Expiratory wheezes

68
Laboratory and Diagnostic Tests (Labs)?????????
Potassium 3.8 mEq/L Sodium 145 mEq/L Serum creatinine 1 mg/dL
FBG 100 mg/dL Total cholesterol 200 mg/dL HDL 35 mg/dL
RBC 4.7 cells/mm3 Hgb 15 g/dL Hct 44
PH 7.40 PaO2 55 mmHg PaCO2 40 mmHg
69
Diagnosis??

• Primary
• 1)Asthma
• 2)Hypertension
• Secondary
• 1)Benign prostatic hyperplasia
• 2)Rheumatoid arthritis
• Problem list

70
Problem List
Current medical problems Goal of therapy Measurable endpoint
Primary 1)Asthma Symptom control Prevent asthma episodes or attacks PEFR No DOE, SOB, PND
2)Hypertension Prevent CHD, Stroke and Nephropathy BP
Secondary 1)BPH Symptom control DRE (digital rectal exam) UFR (urine flow rate)
2)RA Improve QOL Arrest or retard disease progress Swollen tender joints RF, ESR, ANA, CBC X-Ray
71
Current Drug-Therapy Problems
Subjective and Objective Subjective and Objective
Problem(subjective and objective) Current medication
S Pertinent medical HxAsthma x 20 yrs RA x 5 yrs BPH x 1yr ago HTN x 5wks ROS respiratory distress with severe dyspnea wheezing and coughing Tobacco use 0.5 pack/week alcohol use 6 pack / week caffeine use 2 cups of coffee every morning Use a herbal product to treat his BPH Furosemide 40 mg po q AM Albuterol inhaler 2 puffs qid prn Beclomethasone inhaler 1 puff qid Ibuprofen 800 mg po tid Herbal product with licorice po qd Acetaminophen po prn
O 175cm , 95.4kg HR120 BP160/100 RR31 T38.5? Expiratory wheezes PH 7.40 PaO2 55 PaCO2 40 Admitted to hospital 3 times/past 2 yrs for AE of asthma BP 150/95 mmHg previous office visit 5 wks ago Furosemide 40 mg po q AM Albuterol inhaler 2 puffs qid prn Beclomethasone inhaler 1 puff qid Ibuprofen 800 mg po tid Herbal product with licorice po qd Acetaminophen po prn
72
Current Drug-Therapy Problems
Assessment Assessment
Etiology (or risk factors) Evaluate need for therapy evaluate current therapy (Evidence need for therapy evaluation)
AE of asthma Primary therapies for AE (most safely undertaken in a hospital or hospital-based ER) Repetitive administration of rapid-acting inhaled ß2-agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function
Inadequate response to treatment for HTN D/C herbal product with licorice ( has been shown to have an aldosterone-like action) Both ibuprofen and licorice can cause an inadequate response to HTN therapy If BP remains elevated, the clinician should consider initiating ana-blocker
Inadequate BPH treatment The preferred therapy for this pt may be a-blockers (the favorable effects on prostatism and dyslipidemia-decrease LDL-C and increase HDL-C Postural hypotension is commonly experienced witha-1 blockers because of the direct action The first-dose phenomenon is characterized by transient dizziness,faintness, palpitations, and syncopy occurring within 3 hrs of the first dose.
73
Current Drug-Therapy Problems
Plan Plan Plan
Recommended drug treatment, drug to be revised, further test Goal and monitoring parameters (toxic and therapeutic) Patient education
IV methylprednisolone 60-80 mg or Hydrocortisone 300-400 mg or oral prednisolone 0.5-1 mg/kg for 7-10 days Decrease symptom PEFR (GINA 2004) Report any ? in SOB, DOE, PND Techniques in use of medications Smoking cessation
D/C herbal product with licorice BP check daily BP in 1wk lt 140/ 90 (JNC VIII) Teach pt how to self measurement of BP Remind pt that home measurement device should be checked regularly for accuracy Lifestyle modification recommendations (5 modifications)
Usual dose Prazosin 2-30 mg ,bid-tid Terazosin 1-20 mg ,qd-bid Doxazosin 1-16mg ,qd (first dose at hs) Decrease symptom (bladder outlet obstruction, postvoid residual urine volume, reverse urinary retention / RI May be avoided by having the pt take the first dose and/or the first increase in dose at bedtime
74
???? ????
?? Un Clos (A Close)-?? Cezanne 1890
75
????

• 920 1050 ???????
• 1050 1200 ??????
• ????? 1050 1100 Type 2 DM--initiate OADs in
  a newly diagnosed DM patients
• ????? 1100 1110 Hypertension--inappropriate
  drug of choice and inadequate BP control for HTN
• ????? 1110 1120 Hyperlipidemia--initiate
  lipid lowing agents for a patient with high CV
  risks
• ????? 1120 1130 Obesity, metabolic
  syndrome--pharmacotherapy of obesity and
  metabolic syndrome
• ????? 1130 1140 ?????????
• ????? 1140 1150 SOAP??????
• 1150 1200 ?????

76
??????

1. ???????,???????SOAP,????????????"S"?????"O"?????"A
   "?????"P",????????????????
2. ??????????,????????,???????????SOAP????????,??????
   ????????"PLAN"???,?????????????????SOAP????(??????
   ???????)?
3. ??????????????,?????????????,???????????????,?????
   ?????(?????,?????????...??)?
4. ?????SOAP??,????A?P??????

?????????????????????