Patient Assessment Flashcards

Question

Collect

Answer 1

``` Medical terms/abbreviations Medical history Medication reconciliation Lab results Patient lifestyle habits/preferences/beliefs Socioeconomic factors ```

Answer 2

``` Clinical Data Interpretation Risk factors Patient specific outcomes Cultural factors Health literacy Access to medications Preventative Health Identify problems Develop prioritized problem list ```

Answer 3

Address problems and make recommendations to optimize therapy practicing evidence based medicine Identify goals of therapy to achieve clinical outcomes

Answer 4

Communicate/Document plan with others Initiate, modify, DC med therapy Pt education and self-management training Preventive care strategies

Answer 5

Monitor Clinical endpoints Monitor outcomes of care/care goals Re-evaluate at each encounter

Answer 6

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)

Answer 7

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

Answer 8

Collect and organize necessary subjective and objective information in order to understand the relevant medical/ medication history and clinical status of the patient

Answer 9

Patient Community Pharmacy records Medical Record

Answer 10

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.

Answer 11

1. Every patient’s disease state - -> Could be controlled or not 2. Preventative Health - -> Immunizations, screenings etc… 3. Drug Related Problems (DRPs)

Answer 12

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

Answer 13

any mistake at any stage of the medication use process

Answer 14

result of an injury to a drug-related intervention, regardless of whether an error has occurred

Answer 15

All MEs can be prevented ADEs: preventable, non-preventable or potential MEs: result from any step of medication0use process

Answer 16

event or circumstance involving a pt’s drug treatment that actually, or potentially interferes with achievement of optimal outcome

Answer 17

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

Answer 18

``` 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 ```

Answer 19

``` 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 ```

Answer 20

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

Answer 21

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

Answer 22

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.

Answer 23

1. recommended therapy 2. drug/food to avoid 3. further tests and follow-up 4. goals 5. therapeutic monitoring parameters 6. toxic monitoring parameters 7. patient education

Answer 24

The pharmacist implements care plan in collaboration with other health care professionals and pt or caregiver

Answer 25

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.

Answer 26

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)

Answer 27

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