Intro to Pharmacy Practice - Final Exam

Prescription

order for medications, devices, or services issued for a specific patient by a licensed, authorized medical practitioner

What do prescriptions commonly refer to?

drug products for outpatients who obtain their prescribed medications from retail pharmacies, mail order pharmacies

Medication Orders

usually used when referring to drug orders for patients in hospitals, nursing homes or other institutional settings

What is an important piece of medication orders?

time

What are the parts of a prescription?

-patient information

-date issued

-Rx symbol (superscription)

-med name, strength, and dosage form and quantity (inscription)

-directions for pharmacist (subscription)

-directions for patient (signa) sig codes

-refill information

-prescriber information

Rx Superscription

Rx symbol

Inscription

med name, strength, dosage form and quantity

Subscription

directions for pharmacist

Sigma

directions for patient

What type of numbering systems are used in prescriptions and med orders?

roman numerals and military time

What are the 5 main components of direction for use in prescription?

1. verb

2. quantity

3. dosage form

4. route

5. frequency

Auxiliary Label

-placed on drug product containers or pre-printed vial label to give patient, caregiver, or health care provider important info for storing or using product

-NOT a substitution for counseling

What type of auxiliary label is necessary?

'Shake Well' for suspension

National Drug Code

unique product identifier used in US for drugs intended for human use

Labeler Code

4-5 digits that signifies the labeler that manufactures, repacks, or distributes a drug product

Product Code

3-4 digits that identifies specific strength, dosage form, and formulation for a specific firm

Package Code

1-2 digits that identifies packs forms and sizes

American Hospital Formulary Service Classification Number

drug information source (red book) which assigns unique numeric identifiers that represents a specific therapeutic class

Chemical Abstracts Service Registry Number

unique numerical identifier assigned by the Chemical Abstracts Service, a division of the American Chemical Society to every chemical substance described in the open scientific literature

Categories of Medications

-prescription (legend) medications

-controlled medications

-compounded medications

-over the counter medications

-herbals - complementary and alternative medicine (CAM)

-behind the counter medications

-investigational drugs

Prescription (legend) Medications

medications requiring a prescription, also called legend drugs prescription only

Controlled Substances

prescriptions drugs whose potential for abuse justifies special restrictions imposed by federal and state governments and each state varies

What phrase is required by controlled substances within the label?

"Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed."

Schedule I

-highest potential for abuse

-no medicinal use in US

-cannot be used safely

-heroin, LSD, ecstasy

Schedule II

-higher potential for abuse with possibility for severe psychological or physical dependence

-accepted for medical use in US

-some in combination with other schedule drugs

-morphine, fentanyl, codeine

Schedule III

-less potential for abuse

-accepted for medical use in US

-abuse may lead to low/moderate physical dependence or high psychological dependence

-anabolic steroids or some barbiturates

Schedule IV

-lower potential

-accepted for medical use in US

-benzodiazepines and phenobarbital

Schedule V

-lowest potential for abuse

-SD does not have this category

-consists primarily of preparations containing limited quanities of certain narcotics

Compounded Medications

-specific record keeping

-compounding I suppose

Over the Counter Medications

-may be purchased without a prescription

-safely properly self administered without supervision of prescriber

-usually not habit forming and low potential for adverse effects

Complementary and Alternative Medicine

-not part of western/traditional medicine

-without prescription

-not FDA approved

What happens if FDA determines dietary supplement to be unsafe?

may issue a warning or require removal from the market

Behind the Counter Medications

may be purchased without prescription but placed behind counter to prevent misuse

Investigational Drugs

-drug before marketing applicaion approval

-typically utilized by clinical investigators

Four Stages of Drug System

1. research and development

2. regulatory review

3. medication manufacturing, distribution, and marketing

4. medication use system

Medication Use System

-process by which individual patients obtain and use medications

-combination of interdependent processes that share the common goal of safe, effective, appropriate, and efficient provision of drug therapy to patients

Stakeholders and Influential Groups in the US Drug System

• Drug users

• Drug manufacturers and distributors

• Drug providers

• Payers

• Regulators

• Policymakers

• Accrediting, patient safety, and quality improvement organizations

• Medical journal editors and general media

Precise Medical or Scientific writing

• clear, concise, and accurate word choice

• conveys, describes, and evaluates facts

• formal in tone

Literary or artistic writing which

• seeks to entertain or portray

• evokes images and emotions with descriptive words

Professional Writing Examples

• journal articles

• books

• newsletters

• medication evaluations

• policies and procedures

Prepare to Write

• Spend more time…

• Spend less time…

More time in preparation

Less time in writing, revising and editing, proofing, and correcting

Benefits to preparing

• less time spent clarifying and rewriting

• more positive, professional image

• achieve the results you need

Preparing to Write Steps: (5)

Step 1: Consider your writing from the reader’s point of view

Step 2: Determine your primary purpose

Step 3-5: Determine your topic

• 3: Compose a key part that delivers important message

• 4: list facts and ideas

• 5: group points into categories

Tips for Successful Technical Writing

1. 1.      Model your writing after other well-written papers, journal articles, etc.

2. 2.      Use writing style manuals, dictionaries, thesauruses, spell-checkers, etc. for word ideas, proper grammar and correct spelling.

3. 3.      Carefully edit your writing, then ask someone else to read and edit. Proofread by reading out loud and reading long words syllable by syllable.

4. 4.      Start the project far enough in advance to allow for revision and editing of a rough draft. Revise and edit the draft. Wait a few days, then read it again to determine if errors or unnecessary content remains.

5. 5.      Keep track of information sources. Know exactly which are your own words, and document sources of the other words.

6. 6.      If writing for a specific journal, book, newsletter, etc. – review the ‘instructions for authors’.

Word Choice, Mechanics, Sentence Construction

1. Avoid fluff

2. Say precisely what you mean

3. Other advice and reminders

4. Writing Numbers

5. Correct Use of the Metric System

Avoid fluff

1. a)     Omit language intended to add fluff.

2. b)     Try to use short, simple, and concise words and sentences.

3. c)     Avoid wordy or run-on sentences and phrases.

Say precisely what you mean

• Watch spelling

• Watch abbreviations

Other advice and reminders

• avoid bias

• no contractions

• avoid using /

• avoid pronouns, especially I, we, us

• generic (lowercase), brand (Capital)

• hyphen used with dosage form, not with only dose and no dosage form

• be mindful of spaces

Writing Numbers

• Use words for numbers one through nine and beginning a sentence

• Use numerals for 10 and above, in a sentence containing two or more numbers, all units of time, measurement or money, very large round numbers

Correct Use of the Metric System

• Use a space between numberic digits of a quantity and SI symbol

• No period after symbol

• Do not use trailing or leading zeros

• Use the singular form for symbols and plural form for words

• Uppercase vs. lowercase; L vs g

Diagnosis

determination of the presence of a disease based on the evaluation of symptoms, signs, and test findings

Sign

objective evidence of disease perceptible to the examiner

ex: elevated blood glucose

Sx (symptom)

subjective evidence of disease perceptible to the patient

ex: dizzy

Test findings

ex: blood glucose level of 500 mg/dL

A (assessment)

identification of disease or condition after evaluation of the patient’s

• history, signs and symptoms, laboratory tests, and diagnostic procedures

R/O (rule out)

used to indicate a differential diagnosis when one or more diagnoses

• are suspected; indicates further work-up is required to rule out a Dx

• Ex: R/O hepatitis

Differential Diagnosis

process of differentiating between two or more conditions which share similar signs or symptoms

ex: shortness of breath could be from blood clot, heart failure, asthma, etc

Prescribing

• Advise and authorize the use of (a medicine or treatment)

• Advancing the practice of pharmacy

• State by state basis

Blood Pressure Steps

• Preparation

• Patient Position

• Proper Cuff Size

• Cuff Placement

• The Stethoscope

• Cuff Inflation/Deflation

• Korotkoff Sounds

Preparation

• rest for 5-10 minutes

• quiet, relaxed environment

• nothing to eat, drink, smoke at least 30 minutes

• wait 10 to 15 minutes after a bath/shower

• make sure equipment has been calibrated and is accurate

Patient Position

• Patient seated

• feet flat on floor

• back supported

• bare arm

• arm flexed, palm up

• arm supported

• midpoint of arm at heart level

Proper Cuff Size

• 5 sizes (peds, youth, standard adult, large, and x-large or thigh)

• Bladder length 80% and width 40% of arm circumference

Cuff Placement

• Palpate brachial artery

• Center bladder over brachial artery

• Place lower edge 1 inch above antecubital crease

• Wrap cuff snug, two finger test

Stethoscope

• earpiece forward

• bell vs. diaphragm (tap to confirm)

• place over brachial artery

• use thumb and index finger of non-dominant hand

• hold firmly with light pressure in place

Bulb and valve

• hold bulb in dominate hand

• close valve

Cuff inflation and deflation

• ask patient normal blood pressure

• rapidly inflate cuff 20 to 30 mmHg above patients normal systolic

• Slowly deflate at rate of 2-3 mmHg per second

• Listen until sound disappears; slowly deflate cuff another 10 mmHg

• Rapidly delate cuff; allow patient to rest 1-2 minutes before repeating

Korotkoff Sounds

• Phase I: First appearance of clear repetitive sounds (systolic pressure)

• Phase II: A blowing or whooshing sound

• Phase III: Sounds become louder and crisper

• Phase IV: Sounds are softer and muffled

• Phase V: Sounds disappear (Diastolic pressure)

Record Blood Pressure

• Arm Used

• BP

• Cuff size

• Date

• Patient Position

• Initials

When to notify physician

• Normal 120/80

• BP > 130/80 - hypertension

• BP > 180/120 - Hypertensive urgency/emergency

• Signs and symptoms of hypertensive crisis - chest pain, shortness of breath, bloody nose, headache, dizziness

• Low pressure - dizzy, lightheaded, fainting

Orthostatic Hypotension

• Normal: small decrease in diastolic bp and small decrease in systolic bp

• OH = supine to standing, SBP decrease > 20 mmHg or DBP > 10 mmHg

• Sxs: unsteadiness, dizziness, fainting

Signs/Symptoms of Heart Rate/Pulse Abnormalities

• Racing or pounding in chest

• Chest pain/pressure

• Shortness of breath

• Dizzy/lightheaded

• Fatigue

• Weakness

• Confusion

• Fainting

Blood Glucose - Using Test Strips

• properly store strips and check expiration date

• Code monitor to test strips; match number on bottle to number on meter, change code with each new bottle of strips, some meters don’t need to be coded

Using Control Solution

• verifies if meter and strips are working properly

• Apply/Acts like blood sample

• Number on test strips should match the reading on the meter if you use control solution then meter and strips are working fine

Obtaining Blood Sample

• Gloves

• Wash hands; alcohol not needed

• Dry hands

• Hang hand below heart for 30-60 seconds

• Apply pressure on the finger with opposite hand

• Alternate site testing (forearm, palm of hand, thigh)

Lancing the Finger

• Lancet device (single vs. multi-use)

• Adjust depth of lancet device

• point finger to ground and lance side or tip of finger

Applying the drop of blood

• ensure adequate supply of blood is applied to the test strip

• apply light pressure on the finger to increase size of blood sample

• quickly place blood sample on test strip

• refer to each meter and strip as to where to apply

Stop Bleeding

• apply direct pressure

• apply band-aid

• wear gloves during process

• dispose of lancets in sharps container

• dispose of gloves in appropriate container

Abnormal Blood Glucose Levels

• Fasting (8 hours) > 100 mg/dL is elevated

• Non-fasting blood sugar > 140 mg/dL is elevated

• Blood sugar < 70 mg/dL - hypoglycemia

Hyperglycemia signs and symptoms

• polyuria (urine)

• polyphagia (hunger)

• polydrypsia (thirst)

• Blurred vision

• Weight loss

• Dry mouth

• Infections

Hypoglycemia signs and symptoms

• Shaking/tremor

• Sweating

• Confusion

• Irritability/anxiety

• Headache

• Hunger

• Dizzy/lightheaded

Point of care Testing Devices - most common

• Cholestech - cholesterol

• Coagucheck - INR

• HgbA1c - diabetes

• Strep, influenza, RSV testing

• HIV testing

Cholesterol goals - Healthy adults

• Total cholesterol < 200 mg/ dL

• LDL cholesterol < 130 mg/ dL

• HDL cholesterol

  • > 40 mg/dL men

  • > 50 mg/dL women

• Triglycerides < 150 mg/dL

• Non-HDL < 160 mg/dL

Medication Error

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer

Medication Error Includes: 

• Includes prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

close call (near miss)

event or situation that could have resulted in an accident, injury or illness, but did not – either by chance or through timely intervention; opportunity for learning and developing prevention strategies.

confirmation bias

seeing what one expects to see or what is more common, rather than what is actually there

Prevention of medication errors

• Handling look-alike/sound-alike medications

• Institute for Safe Medication Practices

• Recommendations to improve medication information documentation

Medication Use Process

Several Settings

Several Components

Several Settings

• Community Pharmacies

• Institutional Setting (hospital, etc.) Pharmacy Services

• Clinics via Drug Samples

• Other: Long-term care, home health, infusion centers

Several Components

• Procurement and Storage (of the medication to/in pharmacy)

• Prescribing or ordering the medication (by prescriber)

• Transcribing and reviewing ( in pharmacy)

• Preparing and dispensing the medication (in pharmacy to patient)

• Delivering

• Counsel the patient on the medication

• Administering or using the medication

• Monitor the patient for medication effects and outcomes

• Documentation throughout

Evolution of Pharmacy Practice in the US

• Apothecary

• Drug Dispensing and Distribution

• Clinical Pharmacy

• Pharmaceutical Care

Clinical Pharmacy

concerned with the science and practice of rational medication use. a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health and disease prevention

Pharmaceutical Care

provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. These outcomes are 1) cure of a disease, 2) elimination or reduction of a patient’s symptomatology, 3) arresting or slowing of a disease process, and 4) preventing a disease or symptomatology

Elements of Pharmaceutical Care

• responsible provision of care

• direct provision of care

• caring

• achieving positive outcomes

• improving the patient’s quality of life

Pharmacist’s Patient Care Process Steps

1. Collect

2. Assess

3. Plan

4. Implement

5. Follow up: Monitor and Evaluate

Medication Therapy Management

partnership of the pharmacist, the patient or caregiver, and other health professionals that promotes the safe and effective use of medications and helps patients achieve the targeted outcomes from medication therapy

Patient-Centered Care

Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient guides all clinical decisions

Collect

The pharmacist assures the collection of necessary subjective__ and ___objective___ information about the patient in order to understand the relevant medical/medication history and clinical status of the patient. Information may be gathered and verified from multiple sources, including existing patient records, the patient, and other health care professionals.

Assess

The pharmacist assesses the information collected and analyzes the clinical effects of the patient’s therapy in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care.

Drug Therapy Problems (DTPs)

Undesirable event a patient experiences that involves (or is suspected of involving) drug therapy that actually (or potentially) interferes with a desired patient outcome