UNIT 1 CLINICAL PHARMACY

Clinical Pharmacy

a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention

Rational Selection

Monitoring

Dosing

Control of overall drug therapy

Clinical Pharmacy

it includes broad responsibility for safe and appropriate use of drugs in patients, which includes:

Pharmaceutical Care

is a cooperative, patient-centered system for achieving specific and positive patient outcomes from the responsible provision of medicines

Pharmaceutical Care

Responsible provision of drug therapy for the purpose of achieving definite outcomes to improve patient’s quality of life

Rational Drug Therapy

Requires that patients receive medications to appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community

Medicines Optimization

aims to ensure that the right patients get the right choice of medicine at the right time

Medicines optimization

the purpose is to help patients take their medicines appropriately and by doing so, avoid unnecessary treatment, improve safety and outcomes, and reduce wastage

Pharmacy

• synthesis, chemistry, and preparation of drugs

• product-oriented

Clinical Pharmacy

• analysis of population needs with regard to medicines, ways of administration, patterns of use, and drug effects on the patient

• patient-centered

• patient-oriented

• achieves rational drug use (WHO)

• practiced in both community and hospital setting

Clinical Pharmacy Characteristics

• Pharmacology

• Toxicology

• Therapeutics

• Clinical Pharmacokinetics

• Pharmacoeconomics

Application of different Scientific principles:

Knowledge and Skills of Clinical Pharmacists

• Expert Knowledge on Drug and Non-drug therapy

• Knowledge on lab and diagnostic test

• Drug monitoring and provision of drug information

• Communication skills

• Physical assessment and therapeutical planning skills

• Good understanding of disease process

Roles of a clinical pharmacist

• Interact with the healthcare team

• Provide drug information

• Design and implement therapeutic plan

• Monitor patients response to therapy

• Make therapeutic recommendations

• Interview and assess patient information

• Safe Drug Therapy

• Effective Drug Therapy

• Economic Drug Therapy

• Improve Quality of Life

Aims of Pharmaceutical Care

• Cure the Disease

• Prevent the Disease

• Arrest the Disease Process

Outcomes of Pharmaceutical Care

1. Assessment

2. Care Plan

3. Evaluation

Pharmaceutical Care Process

Assessment

1. Asses the patient for drug related problems.

2. Determine whether drug related problems are being treated

3. Determine whether current drug therapy is appropriate

4. Determine whether additional drug therapy is needed

5. Determine if any of the drug related problems may have been caused by medication

Care Plan

1. Approach normal physiology (i.e., normalize blood pressure)

2. Slow progression of disease (i.e., slow progression of cancer)

3. Alleviate symptoms (i.e., optimize pain control)

4. Prevent adverse effects

5. Control medication costs

6. Educate the patient about his/her medication

Evaluation

1. Specify patient’s progress

2. Monitor potential adverse drug reactions

3. Determine desired end points for each parameter and the frequency of monitoring

Therapeutic Drug Monitoring

Individualization and optimization of dosage to maintain blood-drug concentration within the target range

Therapeutic Drug Monitoring

It is used mainly for monitoring drugs with narrow therapeutic ranges, drugs with marked pharmacokinetic variability, medications for which target concentrations are difficult to monitor, and drugs known to cause therapeutic and adverse effects

Therapeutic Index (TI)

Ratio of TD50 and ED50

Determines how safe or toxic the drug is

TI = TD50/ED50

formula for therapeutic index

Primary

provides the most current information (e.g., journal articles)

Secondary

for selective and quick screening of primary literature (e.g., Abstracting and Indexing Services)

Tertiary

for easy and convenient access; info may be outdated (e.g., textbooks)

Adverse Drug Reactions (ADR)

Any response to a drug that is noxious and unintended, which occurs at doses normally used (vs toxicity) in man for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiologic function

Serious Adverse Event

The patient outcome is death, life- threatening (real risk of dying), hospitalization (initial or prolonged), disability (significant, persistent, or permanent), congenital anomaly, or required intervention to prevent permanent impairment or damage

Pharmacovigilance

Continual monitoring of unwanted effects and other safety related aspects of marketed drugs

Underdeveloped organs

Pediatrics (special populations) problem

gray baby syndrome (Chloramphenicol) and kernicterus (Sulfonamides)

Examples of ADRs in pediatrics associated with UDP- Glucuronosyl acetyltransferase deficiency are

Chloramphenicol

drug in pediatrics that results in gray baby syndrome

Sulfonamides

drugs in pediatrics that results in kernicterus

Comorbidity, polypharmacy, pharmacokinetics, and less functional organ

geriatric (special populations) problem

teratogenic agents

pregnant (special populations) problem

Resuscitation or Code Blue

• Role of Pharmacists:

  • Prepare medications that may be needed during a code

  • Assist with dose calculation to ensure the therapeutic dose

1 mg, every 3-5 minutes , After each dose: 20 mL IV flush

IV Dose

2 to 2.5 mg endotracheally, every 3 - 5 minutes during cardiac arrest if IV or intraosseous route cannot be established

ETT Dose

If the initial dose fails, 0.2 mg per kg of body weight (maximum)

Higher Dose

• Organ dysfunction

  • e.g., CKD, renal dysfunction

  • Malnourisment

  • Age and/or weight

  • Switching between routes of administration

Malnutrition

Deficiency, excess, or imbalance of energy, protein, and other nutrients

Food

Primary malnutrition:

Secondary malnutrition

• Malabsorption disorders (e.g., Celiac disease, Crohn’s disease)

• Chronic illnesses (e.g., cancer, HIV/AIDS)

• Metabolic disorders (e.g., Diabetes)

• Infections and parasites

• Surgical procedures affecting nutrient absorption

Kwashiorkor

It develops in children whose diets are deficient of protein

Marasmus

It develops in children whose diets are deficient of proteins and calories

3 months and 3 years of age

Kwashiorkor occurs in children age

infants under 1 year of age

Marasmus occurs in children age

preserved

In kwashiorkor, subcutaneous fat is

not preserved

In marasmus, subcutaneous fat is

present

In kwashiorkor, oedama is

absent

In marasmus, oedema is

enlarge fatty liver

In kwashiorkor, liver is

no fatty liver

In marasmus, liver is

not very promiment

In kwashiorkor, ribs are

become very prominent

In marasmus, ribs

Kwashiorkor

• lethargic

• muscle wasting mild or absent

• poor appetite

Marasmus

• alert and irritable

• sever muscle wasting

• Voracious feeder

proteins

The person suffering from kwashiorkor needs adequate amounts of

protein, fats, and carbohydrates

The person suffering from Marasmus needs adequate amount of

tube feeding

enteric nutrition is through

Parenteral

method of feeding patients by infusing a mixture of all necessary nutrients directly into the circulatory system. AKA IV nutrition/artificial

IV fluid

• fluid replacement and adjustment of electrolyte imbalance

• supplementary nutrition

• vehicle for administering substance

25-50 ml/ <100

IV fluid small volume

100ml/> 100mL

IV fluid large volume

IV Admixture

Preparations consisting of 1 or more sterile drug preparations added to an IV fluid. Prepared using a laminar flow hood

glucose + amino acids

2-in-1 mixture

glucose + amino acids + lipids

3-in-1 mixture

Anti-Infective Stewardship

Review antibiotic, antiviral, and antifungal medications used by comparing to the patient’s condition, site of infection, culture, and sensitivity results

ASOP (Automatic Stop Order Policy)

Antibiotics must be stopped after 7 days unless otherwise stated on the label

Medication Reconciliation

it is the process of creating the most accurate list possible of all medications a patient is taking- including drug name, dosage, frequency, and route - and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications

Narcotics Stewardship

• AKA Opioid stewardship

• Strategies and interventions involving the appropriate procurement, storage, prescribing, and use of opioids, as well as the disposal of unused opioids when opioids are appropriately prescribed for the treatment and management of specific medical conditions

Pharmacogenomics

Relationship between genomes and efficacy, elimination, and toxicities of medications. Evaluates genetic doe of patients to better predict a drug response

Medication Therapy Management Services

Service that optimizes therapeutic outcomes for individual patients

Medication Therapy Management Services

A systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a list of medication-related problems, and creating a plan to resolve them

Patient Medication Profile (PMF)

Written summary of all the medicines taken regularly, including over-the-counter and complementary medicines . Assist in understanding and managing medicines by informing how, why, and when to take medicine

• Admission Records

• Physician Order Sheet

• Medical/Clinical Abstract

• Medication and IV Fluid Flow Sheet

• Laboratory Flow Sheet

• Ancillary Flow Sheet

Parts of a Patient Medical Chart (PMC)

Admission Records

• Medical records that document a patient’s status

• Initial instruction for patient care

• History and physical examination findings

• Reasons why the patient is admitted

Physician Order Sheet

Instruction directed at medical personnel available to follow up on the procedure given by the doctor

Medical/Clinical Abstract

• Final document that summarizes all the medical records and findings of the patient during hospitalization AKA Discharge summary

Laboratory Flow Sheet

Record and track patient’s lab test results

Ancillary Flow Sheet

Supportive or diagnostic measures that supplement healthcare providers in treating a patient

Medication Flow Sheet

A tracking mechanism in order to keep up with the medications the patient is taking

IV Fluid Flow Sheet

Containing information about the IV fluids provided to the patient

1.General Data

2.Chief Complaint

3.History of Present Illness

4.Past Medical History

5.Social History

6.Family Medical History

7.Medication History

8.Obstetrics Historyand Gynecology

9.Immunization History

10.Review of Systems (ROS)

11.Physical Examination (PE)

12.Present Working Impression

13.Laboratory Summary

14.Patient's Problem List

15.Drug Therapy Plan

16.Pharmacist's Care Plan

17.Consent Form

18.Physician Order Sheet

19.Multidisciplinary Progress Notes

Parts of Medication profile

General data

Name, age, gender, date of admission

Chief Complaint

• Information is subjective

• Reason why a patient seeks medical attention

• NOT YET the diagnosis of the disease

• Based on the patient’s statement

History of Present Illness (HPI)

• Information about the current condition

• Narrative

Past Medical History

• Total sum of the patient’s health status before the present problem

• Information may or may not related to the present illness

Past Surgical History

• Record the patient’s procedures and surgeries

• Includes surgery dates and reports

Social History

• Diet

• Use of tobacco (20 sticks = 1 pack)

• Alcohol/drinking habits

• Illicit drugs

• Marital status

• Occupational history

• Sexual history

Family Medical History

• Medical History of the patiente first-degree relativ

• Including history of certain conditions or diseases in family members (e.b. a history of dementia, cancer, heart, disease, diabetes, epilepsy, etc.)

Medication History

• Current and past medication

• otc drug use

• ADR

• compliance

Obstetrics and Gynecology History

• Details of past and present pregnancy

• Menstrual history

Immunization History

• Vaccines received

• Date recieved

Review of System (ROS)

• Patient's complaints not included in the HPI

• Assessment per organ

Physical Examination: Sign

Takent Note of By: Medical Professional

Characteristcs: Objective, measurable, observable,and can be verified through physicalexamination, laboratory tests, ordiagnostic procedures

Examples: Fever, hypertension, tachycardia,rash, edema, cyanosis, abnormallaboratory results

Physical Examination: Symptom

Takent Note of By: Patient

Characteristics: Subjective, experienced andreported by the patient, and cannotbe directly measured or observed byothers

Examples: Pain, dizziness, nausea, fatigue,headache, shortness of breath,itching

36.5–37.5°C (97.7–99.5°F)

Body Temperature normal value

60-100bpm

Heart rate (pulse) normal value

12-16-20 breaths/min

Respiratory Rate normal value