Transcript Systematic approach to patient therapy assessment What is

• Systematic
approach to
patient
therapy
assessment
What is systematic approach to
patient therapy assessment?
Patient therapy assessment is the
process whereby a clinical
pharmacist integrates general
diagnosis & therapeutic knowledge
with medical & social information
obtained from an individual to
develop an optimal patient –
specific therapeutic plan.
Why is systematic approach to
patient therapy assessment?
To relate knowledge base to the
solution of therapeutic problems
by formulating advice to prescribers
& patients to maximize efficacy,
safety & cost effectiveness.
Construct & defend rational
arguments in support of the advice
so formulated.
When and Where?
In response to a request of
a prescriber.
 In ward rounds.
 In selected patients of high
risk factors.

Ability to interpret laboratory data.
Knowledge of medical abbreviations.
Clinical Pharmacy & Therapeutics,
pp863-870.
Clinical pharmacy & therapeutics, Roger Walker & Clive
Edward, Latest edition.
Clinical pharmacy & therapeutics, eds. Herfindal ET
Gourly DR, Hart LL, Latest edition.
Applied Therapeutics. The clinical use of drugs, Young
LY, Koda-Kimble MA, Latest edition.
Pharmacotherapy, A pathophysiological approacgh,
Dipiro, JT etal., Fifth edition.
Pathophysiology : Biological & Behavioral perspective,
eds. Copstead & Banasik.
Davidson’s principles & practice of medicine, eds.
Edwards CRW, Bourchier LAD, Haslet C, Chilvers ER,
latest edition.
Clinical medicine, eds. Kumar P & Clark M, latest edition.
Organizing information according to
medical problems helps breakdown a
complex situation into its individual parts.
Each medical problem is identified , listed
sequentially, and assigned a number.
Subjective data & objective data in support
of each problem are delineated, an
assessment is made , & a plan of action
identified [SOAP]
A 'problem' can be defined as anything
relating to a patient which may influence
the medical management of that patient.
Thus a problem can be:i) A disease state.
ii) An abnormal finding which is not
attributable to a diagnosed disease state.
iii) Any other factor which may influence
the patients management.
A disease state should be confirmed by
relevant objective findings before it s
listed as a definite problem.
Once this is done, symptoms, signs or
results of investigations are then related
to the disease state and are not
problems in their own right.
For example, a patient admitted to hospital
with chest pain may have had a
myocardial infarction or may have severe
acute angina. Initially his problem is 'chest
pain', but after investigations of ECG and
serum cardiac enzymes, the ,diagnosis of
myocardial infarction can be confirmed or
refuted. His problem then becomes either
'myocardial infarction' or 'acute angina'.
Chest pain is then a symptom of a
diagnosed disease state and is not a
problem in its own right.
Abnormal findings of any sort,
symptoms, signs or results of
investigations which are not known to
be due to any disease state already
diagnosed in this patient are problems
in their own right.
In addition some findings may be
related to existing disease states but
may be sufficiently important to warrant
being classed as separate problems.
For example, a patient with
hypertension may have a degree of
renal dysfunction which is known
to be due to his hypertension, but
this is important for the
management of the patient and
may cause further symptoms itself,
thus it is classed as a separate
problem.
Other factors which may influence a patient's
management are wide ranging and may
include:smoking,
excess alcohol intake,
low intelligence,
confusion,
history of poor compliance,
inability to swallow,
previous adverse drug reactions,
poor social circumstances etc.
Problems can be subdivided into active or
inactive.
Active problems are those which currently
require treatment. For example a patient
diagnosed as having hypertension
adequately controlled by bendrofluazide,
who has developed hypokalaemia would
have two problems, hypertension and
hypokalaemia, both of which are active,
despite the fact that he is at present
normotensive.
Inactive problems are those which have
been treated and treatment has been
discontinued or the problem is resolved by
some other means.
Adverse drug reactions are also inactive
problems, provided the reaction has
resolved.
It is important to be aware of inactive
problems, since despite no longer
requiring therapy they may well influence
present and future management of a
patient.
INTERACTIONS BETWEEN
PROBLEMS, DRUGS AND
GOALS OF THERAPY
Interactions may occur between drugs,
between drugs and problems
and between problems.
Any type of interaction may affect the
achievement of goals of therapy by
altering handling, toxicity or efficacy of
drugs or by worsening or causing
problems.
1. Problems which may affect other
problems:Examples are:Renovascular disease causing or
worsening hypertension
Cardiac failure causing reduced renal
function.
Smoking causing chronic bronchitis.
Poor compliance with drugs worsening
any problem for which drugs are
prescribed.
2. Problems which may affect the
achievement of goals of therapy:-
This may include examples such
as:Smoking reduces symptom relief
in asthma
Inadequate knowledge of
medication may prevent effective
use of drug therapy
3. Drugs which may affect the
achievement of goals of therapy:Drugs which alter handling, toxicity or
efficacy of other drugs or worsen problems
will clearly affect the achievement of goals
of therapy.
In addition, some drugs or, more commonly,
drug combinations by being administered
together can actually preclude the
achievement of goals.
An example would be the product Burinex K
causing hypokalaemia which it is
simultaneously attempting to rectify.
4. Goals which are not being
achieved:The whole point of setting goals of therapy
for patients is that they should as far as
possible be achieved.
If any identified goal is not being achieved,
can any contributing factor such as a
problem or drug be identified, or should
drug thereby be altered to improve its
effectiveness?
5. Drugs which can worsen or be a
causative factor of problems:Any problem which is listed as a contraindication to a drug or for which the
recommendation to use with caution is given
suggests that the drug may contribute to or
worsen the problem.
There are therefore hundreds of examples of
this type of interaction. A few are:Beta-adrenoceptor antagonists worsen cardiac
failure
Antipyschotics worsen or cause Parkinsonism.
Hypnotics can worsen impaired cerebral function
in acute liver failure.
Diuretics can worsen or cause hypokalaemia
Subjective data refers to information
provided by the patient or another
person which cannot be confirmed
independently.
Objective data refers to information
observed or measured by the clinical
pharmacist ,laboratory test , BP
measurement.
Results of investigations may include a
wide range of general biochemical and
haematological tests and also more
specific tests selected to aid diagnosis,
assess severity of disease states or
monitor progress in individual patients.
These may include other biochemical
analyses (e.g. thyroid function tests), other
haematological tests (e.g. INR),
electrophysiological tests (e.g. ECG),
radiological procedures (e.g. chest X ray),
microbiological tests (e.g. antibiotic
sensitivities).
After the subjective & objective data
have been gathered in support of
specific listed problems , the clinical
pharmacist should assess the acuity ,
severity & importance of these
problems.
The clinical pharmacist should then
identify all factors that could be
causing or contributing to the
problem.
The plan should consist of a
diagnostic plan & a pharmaceutical
care plan that includes patient
education.
Diagnostic plan:- could include
further diagnostic tests, evaluation of
drug –induced problems or referral to
another health care provider.
It describes desired clinical outcomes or
therapeutic objectives.
Examples of clinical outcomes or therapeutic
objectives are:Curing disease [treatment of an infection]
Elimination or reducing patient’s symptoms [pain
control]
Arresting or slowing the disease process
[lowering a patient’s cholesterol or BP to reduce
the risk of CHD].
Preventing an unwanted condition or disease
[immunization, prophylactic antibiotics]
Or improving the quality of life
a) Pharmaceutical care issue, an element
of a pharmaceutical need which requires
to be addressed by a pharmacist.
A pharmaceutical need is defined as a
patient's requirement for a pharmaceutical
product or service. The problem list which
you will identify will contain all of the
patient's pharmaceutical needs but in
addition problems such as adverse drug
reactions, biochemical abnormalities etc.
b) Pharmaceutical action, an
action by a pharmacist to address
a pharmaceutical care issue for a
patient.
c) Desired pharmaceutical output,
a statement of what the
pharmacist aims to achieve for a
patient in relation to a
pharmaceutical care issue.
a) Drug history taking
Drug history taking basically involves
interviewing the patient to obtain further
information relating to drug therapy.
b) Recommending changes to therapy
c) Patient monitoring
d) Patient counseling
e) Ensuring seamless pharmaceutical
care
• Recommending changes to therapy
General factors involved in rational drug
selection
a) Diagnosis, symptoms
The actual severity and stage of the
problem may alter the course of treatment.
For example, a presentation of severe
congestive cardiac failure may require use
of high dose intravenous loop diuretics,
possibly with the addition of metolazone
initially. As symptoms resolve, treatment
may alter.
b) Comparative efficacy of the available
therapies
In patients with duodenal ulceration associated
with Helicobacter pylori, a course of eradication
therapy is more appropriate than sole use of an
H2 antagonist.
c) Patient's other problems
Such situations may contraindicate the use of a
particular drug or group of drugs. For example
hypertensive asthmatic patients should not be
treated with beta adrenoceptor antagonists.
However, it is sometimes possible to choose
one drug to treat more than one problem. For
example, a tricyclic antidepressant would be
most appropriate to use in a depressed patient
with urinary incontinence.
d) Patient's other drugs
There are many examples of clinically important
drug interactions. Some of these may render a
particular treatment unsuitable, while others may
simply increase the need for specific monitoring.
e) Side effects of particular significance
Drugs causing daytime drowsiness are not the
most appropriate for many patients.
f) Pharmacokinetic profiles
This will determine rate and extent of absorption,
excretion etc.
g) Formulation
h) Cost-effectiveness
i) Response to therapy
Having done this, you will be in a position
to identify whether or not a pharmaceutical
care issue exists. There are many types of
such issues, including:Current therapy contra-indicated, clinically
important ,drug-drug interaction ,adverse
drug reactions being experienced ,no
indication for therapy.
Sub-therapeutic dose
Excessive dose
The next stage is to determine the most
appropriate recommendation which may
include:Drug addition
Drug substitution
Drug discontinuation
Change in dose
Change in route
Change in formulation
The final step is to discuss your
recommendation with the prescriber.
Once you have identified that the
patient's therapy is appropriate or
have recommended changes which
have been accepted, the next stage
of the pharmaceutical care plan is to
formulate a monitoring plan to
determine the efficacy and/or toxicity
of treatment.
The relevant pharmaceutical care issue is
simply that there is a need for monitoring,
which may be greater or less depending
on the patient and the drug therapy. As
with the previous aspects of case history
analysis, it is important to use a systematic
approach.
By taking each problem in turn, you can
identify those parameters to monitor to
establish efficacy and those parameters to
monitor for each drug to identify any drug
toxicity.
Reinstituting correct use of a prescription
medication when it is being taken
improperly.
Educating & working with the patient to
self-diagnose.
Evaluate & solve therapeutic problems.
Initiating non prescription drugs.
Non-drug therapy
Reinforcing continuation of already
prescribed medications.
Alerting physician to potential drug –
related problems that can be solved only
through an alteration of the original
prescription[ these include discontinuing
the medication , prescribing an alternative
drug, altering the dosage or the route of
the current medication, adding another
medication]
Referring the patient back to his primary
care provider.