Final Flashcards
what are the three types of assessment basics?
- Drug Related Need
- Drug Therapy problem
- Medication experience
what questions do you ask for drug related needs?
- Appropriate
- Effective
- Safe
- Able/willing to take as instructed
what questions do you ask for drug therapy problems?
- unnecessary drug therapy
- needs additional
- ineffective drug
- dose too low
- dose too high
- adverse drug
- non-adherence
what is a plan and how do you make it for a patient?
develop an individualized pt centered plan that should be evidenced based and cost effective
what are the three main types of communication?
- written documentation
- other written documentation
- verbal communication
what is a patient’s personalized care plan?
summary of drug/disease/PHI, place to record questions for next visit, given to patient and actively engages the patient in care
what is a SOAP note?
formal note seen in a medical record, documents a patient encounter or an interaction, sections formally labeled S/O and A/P
what is an SBAR note?
may include patient medical record or may be used for verbal communication, documents a clinical recommendation of brief patient interaction that requires action, shorter and less detailed than SOAP note
what is a progress note?
LEAST formal abbreviated documentation, may or may not have a structured format, documents a patient encounter or a decision, often used for short interactions or phone follow-up
is the care plan ever entered into the EMR?
NO
what is a chief complaint?
statement of why patient has presented (why they say they’re there)
what is past medical history?
past/active diagnoses, hospitalizations, surgeries, accidents or injuries
what is history of present illness ?
S - Symptoms C - Characteristics H - History O - Onset L - Location A - Aggravating factors R - Remitting factors
What is medication experience?
patients general attitude towards taking medication, what patient wants/expects from drug therapy, understanding of medication etc
what is social and family history?
social - alcohol/caffeine/illicit drug use/tobacco use
family - conditions in 1st degree relatives (cause of death if applicable)
what objective info to collect?
- vitals
- labs/diagnostic tests
- physical exam findings
- current meds
- refill records
- immunization records
- history documented in med record
- drug info
what are the 4 key questions for analyzing medications?
Is the medication indicated?
Is the medication effective?
Is the medication safe?
Can the patient adhere?
How do you prioritize problems?
(1) most urgent - what’s gonna kill them first
(2) address immediately
(3) Address later
what are the dtps associated with indication?
unnecessary drug therapy and needs additional drug therapy
what the dtps associated with effectiveness?
ineffective drug and dose too low
what are the dtps associated with safety?
dose too high and adverse drug reactions
what is the dtp associated with adherence?
non-adherence
what are some common causes of unnecessary drug therapy?
- duplicate therapy
- no medical indication
- non-drug therapy more appropriate
- addiction/recreational drug use
- treating avoidable adverse reactions
what are some common causes of needs additional drug therapy?
- preventative therapy
- untreated condition
- synergistic therapy
what are some common causes of ineffective drug?
- more effective drug available
- condition refractory to drug
- dosage form inappropriate
- contraindication present
- drug not indicated for condition
what are some common causes of dosage too low?
- ineffective dose
- needs additional monitoring
- frequency inappropriate
- incorrect administration
- drug interaction
- incorrect storage
- duration inappropriate
what are some causes of adverse drug reaction?
- undesirable effect
- unsafe drug for patient
- drug interaction
- incorrect administration
- allergic reaction
- dose increase/decrease too fast
what are some common causes of adherence?
- does not understand instructions
- cannot afford drug product
- patient prefers not to take
- drug product not available
- cannot swallow/administer drug
what is the difference between MTM and patient counseling?
mtm - requires documentation, compensation for mtm not related to drug product provision
counseling - patient-centered vs product centered
mtm eligibility for part D
- drug spend in part d medis > $4,044
- multiple part d meds greater than or equal to 2 to 8
- targeted disease states or any chronic disease greater than or equal to 2 to 8
what are the part d mtm targeted disease states (must have at lease 5 to 9)
- alzheimers
- ESRD
- HTN
- CHF
- DM
- HLD
- Respiratory disease
- bone disease
- mental health disorders
essential assessment skills
inquiry listening observational skills pharmacotherapy knowledge organization
what are the 3 activities during assessment
meet the patient
get info from patient/records
make drug therapy decisions
what questions do you ask yourself for assessment of drug related needs?
- Are drug-related needs being met?
- Are all meds appropriately indicated?
- Are all meds most effective available?
- Are all meds the safest possible?
- Able and willing to take meds as intended?
what are the components for goals of therapy?
- goals for each indication
- described with clinical/lab parameters to evaluate efficacy and safety
- include the patient and other practitioners
- realistic to patients present and potential capabilities
- include time frame for achievement
what are the three categories of interventions?
- resolve drug therapy problems
- achieve goals of therapy
- prevent problems
what is a “good” intervention?
- individualized based on conditions, drug-related needs, and drug therapy problems
- all therapeutic alternatives to resolve DTPs are considered and the best selected
- developed in collaboration with patient, family and/or caregivers, and practitioner
- documented
- provides for continuity of care
establishing a follow-up schedule
- determined by goals of therapy
- evaluate efficacy
- evaluate safety
what are the reasons for early follow-up
- past treatment failures
- past adverse effects
- worsening clinical status
- lack of full capability to engage in plan
- high risk medications (and not at goal)
what are the “high risk” medications?
- digoxin
- warfarin/anticoagulants
- antiplatelets
- hypoglycemic
- insulin
what are key factors in determining implementation?
- practice site
- scope of privileges
- type of plan used
what are the only two outcomes in which a change to drug therapy is needed?
worsened or failure
the RESPECT model
R - respect: connect on social level
E - empathy: verbally acknowledge and legitimize patient’s feelings
S - support: ask about, try to understand, and help patient over barriers to care
P - partnership: be flexible
E - expectations: often check understanding
C - cultural competence: respect the patient and his/her beliefs
T - trust: work to establish trust
what are non-supportive responses
judging, advising, reassuring, generalizing, distracting
what are the signs of limited literacy?
- excuses
- length of time to complete forms
- inappropriate answers or blanks on forms
- does not turn paper “right-side” up
- frequent errors
- missed appointments
- nonverbal behaviors
what is motivational interviewing?
- person centered
- guided
- goal directed
- seeks patient’s arguments to change
- enhances intrinsic motivation to change by exploring and resolving ambivalence and resistance
READS model
R - rolling with resistance E - expressing empathy A - Avoiding argumentation D - developing discrepancies S - supporting self-efficacy
Change talk DARN model
D - Desire
A - Ability
R - Reason
N - Need
What are the MI tools?
- Ask permission
- The envelope
- The insurance card
- A look over the fence
- importance/confidence rulers
FIG and creating the conversation
F - Follow (reflect)
I - Inform (ask permission) and identify
G - Guide
Tertiary resources
information that has been summarized to provide an overview of a topic
ex) textbooks, internet webistes
Secondary resources
Pubmed
Primary literature
journals
P1 perceived orietation
Acceptance
P1 developmental orientation
minimization
BMI
body mass index
BP
blood pressure
BPM
beats per min
CV
cardiovascular
DBP
diastolic blood pressure
HTN
hypertension
mmHg
millimeters of mercury
RPM
respirations per minute
SBP
systolic blood pressure
Physical appearance (assessment)
age skin color facial features level of consciousness signs of distress nutrition body structure dress/grooming behavior mobility
what meds can cause weigh gain?
steroids, antipsychotics, antidepressants, diabetes meds
what meds can cause weight loss?
ADHD meds, antidepressants, diabetes meds
what is edema?
fluid leaking into tissues or swelling
what are some causes of edema?
Chronic - heart function, kidney function, liver function, meds
Acute - inflammation, injury, diet, blood clot/obstruction, pregnancy, meds
for edema contact MD if
- stretched and shiny skin
- pitting edema(3+ and 4+)
- edema that will not go away after prolonged sitting
when to refer a fever
adults and children: greater or equal too 104 degrees F(either symptomatic or nonresponsive and lasts longer than 3 days)
cluster headache
Cluster Headaches Characteristics: Male Female Onset around 30 years old Duration of 15 minutes up to 3 months Causes Hypoxia Sudden release of histamine or serotonin
cluster headache symptoms
Cluster Headaches Symptoms Constant and severe pain Usually unilateral; centered around the eye Episodic or chronic Tearing of affected eye Drooping eyelid Nasal stuffiness Nausea and vomiting Photophobia Phonophobia
migraine characteristics/causes
Migraine Headaches Characteristics: Female Male Causes Hormonal, vascular changes, or neuronal changes Change in sleeping patterns Missing meals Increased intake of fatty foods Weather changes Onset between 15 - 35 years old Duration per episode: 4 hours - 3 days
migraine symptoms
Migraine Headaches Symptoms Pulsating or throbbing pain Usually unilateral near the temples Nausea/Vomiting Sensitivity to light, sound, movement Warning signs may occur hours to days before episode Psychologic, neurologic, or autonomic Roughly 10% of patients experience an aura
tension headache
Tension Headaches Most common type of headache Causes Stress or anxiety Symptoms Often described as "band-like" pain Dull, non-pulsating tightness/pressure Usually bilateral Episodic or chronic Sensitivity to light and sound (photophobia and phonophobia)
when to refer a headache
Referral Refer if any factor is present • Patient has symptoms suggestive of migraine or cluster headache • Headache associated with significant hypertension • Headache lasting >10 days • >3 headaches per week • Last trimester of pregnancy (preeclampsia) • Stiff neck (possible infection) • Head trauma • Symptoms resistant to self-care
conjunctivitis
Conjunctivitis Conjunctiva Clear membrane lining the inner surface of the eye and eyelid Conjunctivitis (AKA pink eye) 0 Inflammation of the conjunctiva Meds that cause conjunctivitis: Amiodarone Isotretinoin Bisphosphonates COX-2 inhibitors
viral conjunctivitis
Viral Conjunctivitis Cause Typically preceded by sore throat or cold (Adenovirus) c Contagious Symptoms Pink/red eye Watery discharge Blurred vision Low-grade fever Duration: 1-3 weeks Only symptomatic treatment Lubricants (e.g. artificial tears) Ocular decongestants (e.g. Naphazoline - Naphcon-A @ )
bacterial conjunctivitis
Bacterial Conjunctivitis Common bacterial causes: S. aureus, S. epidermidis, S. pneumoniae, H. influenzae Symptoms Pink/red eyes Purulent discharge (green(yellow) Eye discomfort/pressure Crusted eyelids Eyelid edema Blurred vision Duration: roughly 2 weeks Treatment: requires antibiotics Contagious
allergic conjunctivitis
Not Contagious Allergic Conjunctivitis Cause: exposure to allergens Signs/symptoms Pink/red eyes Clear watery discharge May be stringy and white Burning or itching Eye discomfort Eyelid edema Usually affects BOTH eyes Treatment 0 Topical antihistamine Pheniramine eyedrops - Naphcon-A Mast cell stabilizers Cromolyn eyedrops Anti-inflammatory agents Naphazoline eyedrops - Naphcon-A
glaucoma
Glaucoma Group of eye disorders involving optic neuropathy Changes in optic disc o Loss of visual sensitivity & field
Caused by: Reduced blood flow, retinal ischemia, increased intraocular pressure Primary (hereditary) vs. Secondary (disease, trauma, or drugs) Not Contagious Development of Glaucoma Healthy eye Vitreous body Flow Of aqueous humour Drainage canal Glaucoma 1. Drainage canal blocked; build-up of fluid 2. Increased pressure damages blood vessels and optic nerve Symptoms Occurs after significant damage
blepharitis
Blepharitis Infection of eyelid which may lead to sty formation Caused by bacteria Hands Cosmetics Contact Lenses Symptoms Lump on or near edge of eyelid Painful Swollen Pus-filled Treatment Warm compress Lubricants (e.g. artificial tears)
eye problems when to refer
Referral Refer if any factor is present • Symptoms of infection • Conditions resistant to self-care (72 hours) • Exposure to chemicals • Trauma to eye • Glaucoma • Signs/symptoms of vision loss
eye drop administration instructions
Eye Drop Administration
up PATIENT
CARE
IMPLEM
1.
2.
3.
4.
5.
6.
7.
Wash your hands with soap and water before using this medicine.
Remove cap without touching the dropper lid
Lie down or tilt head back. With your index finger, pull down the lower lid of
your eye to form a pocket and hold the dropper directly over eye with other
hand (without allowing dropper to touch eye or eyelid)
Look up (away from tip) and place drop into the pocket made between your
lower lid and eyeball
Hold eyelid for a moment allowing solution to spread
Gently close your eyes apply light pressure to nasolacrimal opening on side of
nose for 15-30 seconds to limit systemic absorption or loss of product
Wash hands thoroughly again
otitis media
Otitis Media Inflammation of middle ear Common in children <3 o years of age Causes o o o o Bacterial Viral Allergies Irritants ( e.g. cigarette smoke)
types of otitis media
Types of Otitis Media
L......J AOM Most common Rapid onset symptoms: pain, fever, discharge, redness, pulling at ears, irritable, crying Treatment: antibiotics, analgesics, antipyretics, local heat I.............J OM + E Not associated with symptoms of infection Symptoms: rhinitis, cough, diarrhea Treatment of symptoms: analgesics, antipyretics, local heat
otitis externa
Not Contagious Otitis Externa (Swimmer's ear) Inflammation of skin lining the outer ear canal Causes 0 Prolonged exposure to moisture or injury to ear Bacterial or fungal growth Risk factors: Disrupting the externa with cotton swabs or hairpins Symptoms Pain, ear discharge, hearing loss, itching, swelling or redness, burning, stinging, fever Treatment Antibiotics, glucocorticoids, acidifying solutions such as aluminum acetate Warm water or saline
cerumen impaction
Not Contagious Cerumen Impaction Buildup of cerumen (ear wax) leading to blockage of ear canal Ear wax protects the ear Traps dust and prevents bacteria and small objects from entering ear o Too much wax can block the ear canal o Symptoms Earache, fullness in ear, tinnitus, partial hearing loss, itching o Treatment 0 o 0 o Carbamide peroxide (Debrox@) Baby oil Glycerin (Neotic @) Ear candling (not recommended)
water clogged ears
Water Clogged Ears Causes Swimming Bathing Scuba diving Being in a humid climate Symptoms Ear fullness Gradual hearing loss Itching o Ear drying agent Isopropyl alcohol (Swim- Ear plugs (prevention) Low heat
ototoxicity
Ototoxicity Damage to the hearing or balance functions of the ear 0 Reversible vs. Irreversible Causes 0 Chemicals Infections Symptoms Tinnitus, hearing loss, dizziness, loss of balance Medications Causing Ototoxicity = Quinine Salicylates (aspirin) Aminoglycosides Platinum antineoplastic agents Loop Diuretics
ear problems: when to refer
Referral Refer if any factors are present Hearing loss, ear pain, drainage, tinnitus • Symptoms of infection • Symptoms of otitis media and externa • Perforated eardrum Foreign objects in ear
ear drop administration
Ear Drop Administration
up PATIENT
CARE
IMPLEM
1.
2.
3.
4.
5.
6.
7.
8.
9.
Wash hands with soap and water, then dry
Clean outside of ear with a damp cloth, don’t let water into ear
Hold container in your hands for a few minutes to warm drops
If the contents are cloudy, shake the container
Tilt head to the side, open container, draw solution into dropper (don’t touch
the dropper to the ear)
Pull ear back/upwards (adult) or back/downwards (child)
Drop appropriate amount of drops into ear, keep head tilted several minutes or
insert piece of cotton to prevent drops from draining out
Apply light pressure to tragus to ensure appropriate administration
Wipe excess, close container, and wash hands
sinusitis
Sinusitis (head cold)
Inflammation and swelling of sinuses
Interferes with drainage & causes mucus buildup
Viral sinusitis
Symptoms last up to 10 days
0 Symptoms: HA, congestion, low fever, nasal discharge , and
halitosis
Bacterial sinusitis
Symptoms increase in severity after 7-10 days
Contagious
Symptoms: worsening congestion, facial pain, thick yellow-green
nasal discharge, toothache, fever, halitosis
Treat symptoms with oral or topical decongestants
(e.g. Pseudoephedrine - Sudafed @ or oxymetazoline - Afrin @ )
AVOID antihistamines
SINUSITIS
allergic rhinitis
Not Contagious Allergic Rhinitis Inflammation of nasal mucous membrane Cause 0 Exposure to allergen Types: Seasonal Persistent (perennial) Treatment: Oral or topical antihistamines Symptoms 0 0 0 Clear rhinorrhea Sneezing Congestion Post-nasal drip Itching eyes, ears, nose, throat Watery eyes Periorbital swelling (Oral: Cetirizine - Zyrtec @; Topical: Azelastine -Astelin @) 0 Oral or topical decongestants (Oral: Pseudoephedrine - Sudafed @; Topical: Oxymetazoline - Afrin @ ) Intranasal corticosteroids o (e.g. Fluticasone - Flonase @)
nasal self care
Self Care Non-pharmacologic options Allergan avoidance Nasal rinses (Neti Pot) Vaporizers Adequate hydration Saline nasal sprays
nasal refer if
Referral Refer if any factors are present Severe HA not relieved by OTC products Symptoms of systemic infection Symptoms lasting >10 days Cold that worsens after 7 days Changes in vision Symptoms resistant to self-care
nasal spray administration
Wash hands thoroughly with soap and water
Blow nose gently before using spray
Tilt head slightly forward
Breathe out slowly
Gently insert the bottle tip into one nostril, pointing the tip away from inside of
nose (septum)
Squeeze the pump while breathing in slowly
Repeat in other nostril
Wash hands thoroughly with soap and water
cold sores
Cold Sores Blisters located on lips, chin, cheeks, or in nostrils Common cause: Herpes simplex virus 1 (HSV-I) Recurrences likely due to stress or weakened immune system Symptoms Red, painful blisters, oozing/yellow crusting of blister, tingling & itching Treatment (self limiting) Topical antivirals - docosanol (Abreva Contagious
canker sores
Not Contagious Canker Sores Small, round sores inside of mouth 0 Cheek, under tongue, gums, or in back of throat Causes 0 Stress o Food allergies Hormonal changes 0 Malnutrition B-12, folate, zinc, iron Symptoms Sore usually has red edge with white center 0 Painful Treatment (self-limiting) Local anesthetics (benzocaine)
gingivitis
Not Contagious Gingivitis Inflammation of the gums Causes Bacteria leading to accumulated plaque Poor hygiene Symptoms Red/tender gums Swollen gums Gums that bleed easily Receding gums Bad breath
thrush
Not Contagious Oral Candidiasis (Thrush) Fungal infection of the mouth Cause Candida albicans Risk Factors Symptoms Creamy white lesion Cottage cheese appearance Slight bleeding if lesions are scraped 'Cotton mouth' sensation
Weak immune system Dentures Infants Steroid medications Smoking Dry mouth Loss of taste
oral problems refer if
Referral Refer if any factors are present • Lesions associated with significant pain/large area • Gingivitis • Oral candidiasis • Symptoms lasting >14 days • Immunocompromised patients • Frequent recurrence of cold sores • Symptoms resistant to self-care
pharyngitis
Pharyngitis Inflammation of the throat Non-infectious Allergies Sinusitis Post-nasal drip Malignancies Viral Cough Scratchy throat Bacterial (strep throat) Contagious Pain (worse when swallowing or talking) Scratchy throat Dry throat Swollen or red glands/tonsils White patches on tonsils
oral problems refer if
Referral Refer if any factors are present Symptoms of infection (strep throat) Difficulty breathing Difficulty swallowing Symptoms >7 days
basic CV pathophys
Electrical impulse generated by the sinoatrial (SA)
node
Impulse travels to the AV node
1/10 second delay, passes through Bundle of His,
then right and left branches
Impulse spread throughout ventricular myocardium
through Purkinje fibers
ASCVD
10/24/19 Atherosclerotic Cardiovascular Disease (ASCVD) • Acute coronary syndromes (ACS) • History of Ml • Stable or unstable angina Coronary ot other arterial revascularization • Stroke/TlA Peripheral artery disease (atherosclerotic origin) 7 Atherosclerotic Cardiovascular Disease (ASCVD) 8 Risk Factors for Coronary Heart Disease Causative • Cigarette smoking • Hypertension • Low high-density lipoprotein cholesterol (<40 mg/dL) • High total and low-density lipoprotein cholesterol • Type I and type 2 diabetes mellitus Predisposing • Obesity/overweight • Physical inactivity • Family history of premature coronary heart disease (in male, first-degree relative <55 years; in female, first-degree relative <65 years) • Age (men 245 years; women 255 years) • Insulin resistance 4
angina
intermittent chest pain cause by temporary oxygen insufficiency and myocardial ischemia
HF - compensatory responses
Cardiac dilation - Residual blood accumulated in the ventricle - Causes stretching of myocardial fibers and dilation of ventricle Cardiac hypertrophy - An adaptation to the increase diastolic volume - Causes increased ventricular muscle mass and wall thickness Activation of sympathetic nervous system - Release of norepinephrine and other catecholamines in response to reduced CV output and tissue perfusion - Causes increased HR and contractility to maintain normal CV output Stimulation of reninangiotensin-aldosterone system (RAAS) - Due to reduced renal perfusion through sympathetic nervous system activation - Causes aldosterone release àsodium and water retention àincreased venous pooling of blood due to failing ventricle
HTN
Elevated SBP > 140 mmHg, DBP > 90 mmHg, or both ● 90% of patients have idiopathic HTN ○ Secondary causes (10%): renal disease, adrenal disorders (primary aldosteronism, Cushing’s Syndrome, or pheochromocytoma), or pregnancy
