Patient Assessment Flashcards
4 roles of a pharmacist
Procurement of the medication
Dispensing of the medication
Patient Education
Monitoring for effectiveness and safety
Social determinants of heath
are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.
Some examples of social determinants of health
Economic stability, Neighborhood and Physical Environment, Education, Food, community and social context, health care system
Health outcomes
Mortality, morbidity, life expectancy, health care expenditures, health status, functional limitations
Prejudice
A preconceived opinion that is not based on reason or actual experience
Bigotry
Intolerance toward those who hold different opinions or are different from oneself
Discrimination
The unjust or prejudicial treatment of different categories of people or things, especially on the grounds of race, age, or sex
Racism
Prejudice, discrimination, or antagonism directed against a person or people on the basis of their membership of a particular racial or ethnic group, typically one that is a minority or marginalized
Implicit bias
Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.
What equations are available for creatinine clearance calculations?
Cockcroft-gault, Jellife, Schwartz, Salazar Corcoran
Calculating GFR
MDRD
MDRD Formula
eGRF –> 175 x (Scr)^-1.154 x (age)^-0.203 x 0.742 [female] x 1.212 [black]
Effects of implicit bias
Interpersonal interactions
- diagnoses
- pain management
Internal Dynamics
- communication
- collaboration
- performance reviews
- compensation/promotion
Cost/waste
-$310 billion per year
Caring for patients with minoritized ethnicities
Keep an open mind
if you don’t know, ASK
Look beyond race as a risk factor
How does a pharmacist add value
Medication experts
Preventing errors
Easily accessible for patients and others
Diagnose in certain situations
Immunizations
Goals of providing pharmacy service
Cure a disease
Eliminate or reduce symptoms/side effects
Stop/slow progression of a disease
Prevent a disease
Providing pharmacy service involves 3 major functions
Identifying potential and actual problems
Resolving actual problems
preventing potential problems
Pharmacist services that add value
Medication reconciliation Medication Therapy Management (MTM) Comprehensive Medication Management (CMM) Transition of Care Chronic disease state management Renal dosing Antibiotic stewardship Medication assessment Drug information
Transition of Care
The situation where a patient leaves the care of a particular unit or health care facility and moves to another facility or setting, including to his or her own home.
Poorly coordinated transitions of care are caused by
Medication Discrepancies
Readmissions
Adverse Events
Higher costs
medical Reconciliation
The process of comparing a patient’s medication orders to all of the medications that the patient has been taking…to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.
Step 1: review patient chart/profile
Step 2: contact outpatient pharmacy/mail order/SNF/ provider office
Step 3: Interview Patient
Step 4: Communicate to others (verbal/written)
Medical Adherence
The extent to which a patient takes medications as prescribed/directed
Health Literacy
degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions
JCPP Pharmacist Patient Care Process
Collect Assess Plan Implement Follow up: Monitor and Evaluate
Collect
Medical terms/abbreviations Medical history Medication reconciliation Lab results Patient lifestyle habits/preferences/beliefs Socioeconomic factors
Assess
Clinical Data Interpretation Risk factors Patient specific outcomes Cultural factors Health literacy Access to medications Preventative Health Identify problems Develop prioritized problem list
Plan
Address problems and make recommendations to optimize therapy practicing evidence based medicine
Identify goals of therapy to achieve clinical outcomes
Implement
Communicate/Document plan with others
Initiate, modify, DC med therapy
Pt education and self-management training
Preventive care strategies
Follow up
Monitor Clinical endpoints
Monitor outcomes of care/care goals
Re-evaluate at each encounter
Quest Scholar-Mac
Quickly and accurately assess the patient
Ask about current complaint (SCHOLAR)
Symptoms: What are the main & associated symptoms?
Characteristics: What are the symptoms like?
History: What has been done so far? Has this happened in the past?
Onset: When did it start?
Location: Where is the problem?
Aggravating factor: What makes it worse?
Remitting factors: What makes it better?
Other Medications and products?
Allergies?
Coexisting conditions?
Establish that the patient is an appropriate candidate for therapy (particularly OTC)
No severe symptoms
No symptoms that persist or return repeatedly without an identifiable cause
No self-treating to avoid medical care
Suggest appropriate therapy strategies
Medication (OTC and/or Rx)
General care measures (non-drug)
SOAP
Subjective:
Related to the identified problem and associated symptoms as described by the patients themselves (or caregivers)
Descriptive information that the patient provides or that describes how the patient appears and acts.
Cannot be reliably reproduced
Objective:
Observations made and information acquired by a healthcare practitioner determined to be relevant to the identified problem(s)
Results of tests, procedures, and assessments that can be repeated by other health care professionals under similar circumstances to obtain the same information (vital signs, labs, most of the PE, etc…)
Assessment:
Practitioners clinical opinion or judgment about the problem(s) based on S/O data, as well as practitioner’s previous experiences
Look for actual or potential problems
Include rationale for therapy recommendation(s)
Plan:
Course of action deemed appropriate for each problem given the data available
Concise
Do NOT include rationale for recommendation
JCPP: Step 1: Collect
Collect and organize necessary subjective and objective information in order to understand the relevant medical/ medication history and clinical status of the patient
3 Main data sources
Patient
Community Pharmacy records
Medical Record
JCPP: Step 2: Assess
The pharmacist assesses information collected and analyzes clinical effects of pt’s therapy in context of overall health goals to identify and prioritize problems and achieve optimal care.
What is a “problem”
- Every patient’s disease state
- -> Could be controlled or not - Preventative Health
- -> Immunizations, screenings etc… - Drug Related Problems (DRPs)
Developing a problem list
Once clinical data is gathered, a prioritized problem list is developed
A problem is defined as a patient concern, a health professional concern or both
Problems may be diseases, patient complaints, abnormal laboratory values, social concerns, financial concerns, or drug related problems
Multiple approaches to identify/reconcile problems:
Patient Assessment Concept Map
QuEST SCHOLAR-MAC
Medication Errors
any mistake at any stage of the medication use process
Adverse Drug Events
result of an injury to a drug-related intervention, regardless of whether an error has occurred
Medication Errors vs Adverse drug Events
All MEs can be prevented
ADEs: preventable, non-preventable or potential
MEs: result from any step of medication0use process
Drug Related Problems
event or circumstance involving a pt’s drug treatment that actually, or potentially interferes with achievement of optimal outcome
Why do DRPs happen
Systems problems
Clinical inertia:
–> Chronic diseases, many asymptomatic (e.g. diabetes, hypertension, osteoporosis)
–> “recognition of a problem, but failure to act”
Lack of Professional training/experience
Work environment
–> # interruptions, etc…
–> Staffing issues
Poor communication among health care workers
Potential DRP situations
Any new drug therapy Same drug, altered dose Pt required to split tablet Irregular administration schedule e.g. qwk, TIW, qmonth Multiple prescribers Multiple pharmacies Use of herbal products, dietary supplements or vitamins
Consequences of DRPs
Revisit with MD Additional drug treatment to combat DRP Urgent care visit ER visit Hospital admission Long term care facility/rehab admission Death Pt no longer accesses health care system
Detecting DRP
Key information necessary to detect DRPs:
Chief complaint
Patient PMH
Current medications
Medications prior to admission
Renal function (Clcr)
Hepatic function
Monitoring parameters necessary to determine is patient is optimally treated
e.g. BP if pt has HTN, A1C if DM, lipid panel with hyperlipidemia, INR if on warfarin, other drug levels
Resolving DRPs
Alternatives and assessment:
Assess all reasonable drug and non-drug therapy which could benefit this pt and resolve the DRP
Weigh the pros and cons of each option
Evidence based medicine
Pt factors (adherence, side effects, cost, etc…)
What monitoring parameters will need to be addressed?
Indicate the best therapy option
Patient care process step 3: plan
The pharmacist develops an individualized patient-centered
care plan, in collaboration with other health care professionals
and the patient or caregiver that is evidence-based and cost-
effective.
Plan should include
- recommended therapy
- drug/food to avoid
- further tests and follow-up
- goals
- therapeutic monitoring parameters
- toxic monitoring parameters
- patient education
Patient Care Process Step 4: Implement
The pharmacist implements care plan in collaboration with other
health care professionals and pt or caregiver
PATIENT CARE PROCESS STEP 5: FOLLOW-UP: MONITOR AND EVALUATE
The pharmacist monitors and evaluates the effectiveness of the
care plan and modifies the plan in collaboration with other health
care professionals and the patient or caregiver as needed.
therapeutic monitoring parameters
S/sx for progression/resolution of disease state
Tests to monitor disease progression/resolution (and frequency)
Establish endpoints for therapy (when should you discontinue or
change therapy)
Appropriate therapeutic serum drug concentrations
Appropriate alterations in lab values (eg, INR w/ warfarin)
Toxic monitoring parameters
Adverse events of medications and how you would monitor them (eg,
nephrotoxicity = BUN, Scr)
Potential Drug-Drug interactions
Plan to deal with commonly encountered side effects that require therapy
