THE PROVISION OF BASIC PHARMACEUTICAL CARE

Pharmaceutical care: The responsible provision of drug therapy to achieve definite outcomes that are intended to improve a patients quality of life

The key concepts form the basis of pharmaceutical care:

1. A belief and commitment by the practitioner that he/she shares equal responsibility with the patient and prescriber for optimal drug therapy outcomes and is willing to make this belief the driving force of practice. 2. The practitioner must be able to establish a trusting professional-patient relationship. 3. The formal documentation, not only of the pharmaceutical care plan but also of all clinical interventions and therapeutic outcomes. These records enhance the

continuity of care and can be used to communicate with other providers involved in the patients care. ESTABLISHING THE PATIENT RECORD The patient record provides readily available information that is needed to identify and assess medical problems. It is necessary for designing patient-specific care plans and documenting pharmaceutical care. The development of a patient database by community pharmacists primary entails taking a detailed history from the patient and supplementing this history with direct observations (e.g., physical appearance, mental acuity, insulin-injection technique), physical examination (e.g., BP, pulse), and laboratory tests (e.g., blood glucose or cholesterol levels). KNOWLEDGE

 To establish an accurate patient record, the practitioner must have a good understanding of the pathophysiology and clinical presentation of commonly encountered medical conditions so that he/she can correlate certain signs and symptoms with diseases. Pharmacist must have a clear understanding of the appropriate use of drugs that are prescribed commonly to manage these diseases, including a thorough knowledge of pharmacology, how drugs are used to treat disease, and most important, the expected outcome of the therapy.

SOURCES OF PATIENT INFORMATION Successful patient assessment and monitoring requires the gathering and organizing of all available information. The source of information: 1. The patient or a family member is always the primary source information. 2. Previously prescribed therapy.

 Data-Rich Environment In a Data-rich environment such as hospital, a wealth of information is available to practitioners. Objective data regarding diagnosis, physical examination, laboratory and other test results, vital signs, weight, drug dosing, intravenous flow rates, and fluid balance are readily available. Data-Poor Environment In reality, pharmacists often are required to make assessments from a limited database. Two valuable sources of information are still available: 1. the medication profile, and 2. The patient.

Interviewing the patient A successful patient interaction will be obtained if the pharmacist has an ability to use communication principles (e.g., listening,

body language, voice intonation) and history taking skills.

IMPORTANCE OF INTERVIEWING THE PATIENT Establishes professional relationship with patient to: 1. Obtain subjective data on medical problems 2. Obtain patient-specific information on drug efficacy and toxicity 3. Assess patients knowledge about attitudes toward and pattern of medication use 4. Formulate problem list 5. Formulate plans for medication teaching and pharmaceutical care

How to set the stage for the interview 1. Have the patient complete a written health and medication questionnaire if available 2. Introduce yourself 3. Make the setting as private as possible 4. Do not allow friends or relatives without permission of patient 5. Do not appear rushed 6. Be polite 7. Be attentive 8. Maintain eye contact 9. Listen more than you talk 10. Be nonjudgmental 11. Encourage patient to be descriptive 12. Clarify by restatement or patient demonstration (e.g., of a technique). General Interview Rules 1. Read chart or patient profile first 2. Ask for patients permission or make an appointment 3. Begin with open-ended questions 4. Move to close-ended questions 5. Document interaction.

Information to Be Obtained 1. History of allergies 2. History of adverse drug reactions 3. Weight and height 4. drugs: dose, route, frequency, and reason for use 5. Perceived efficacy of each drug 6. Perceived side effects 7. Compliance to drug regimens 8. Nonprescription medication use 9. Possibility of pregnancy in women of childbearing age 10. Family or other support systems.

ORGANIZING THE PATIENT RECORD Pharmacists who provide pharmaceutical care should develop standardized forms to record patient information. Standardization facilitates quick retrieval of information, minimizes the inadvertent omission of data, and enhances the ability of other practitioners to use shared records.

The patient record can be divided into sections such as the history (the medical history, the drug history, and the social history), assessment, and plan (included expected outcomes). MEDICAL HISTORY The medical history is essential to the provision of pharmaceutical care. The medical history can be as extensive as the medical records that are maintained in an institution (hospital) or it can be a simple (but well-designed) patient profile that is maintained in a community pharmacy. The purpose of the medical history is: 1. to identify significant past medical conditions or procedures; 2. to identify, characterize, and assess current acute and chronic medical conditions and symptoms;

3. to gather all relevant health information that could influence drug selection or dosing (e.g., function of major organs such as the GIT, liver, and kidney that are involved in the drug absorption and elimination; height and weight; age and gender; pregnancy and lactation status; and special diets) Putri Jenaka (P.J.), a 45-year-old woman of normal height and weight, states that she has diabetes. What questions might be the pharmacist asks of P.J. to determine whether type 1 or type 2 disease should be documented in her medical history? The questions below will generate information to assist in the determination of whether she has type 1 or type 2 diabetes mellitus (to confirm the diagnosis). 1. How old were you when you were told you had diabetes?

2. Do any of your relatives have diabetes mellitus? What do you know of their diabetes? 3. Do you remember your symptoms? Please describe them. 4. What medications have you used to treat your diabetes? Note: a person with type 2 diabetes is likely to be an overweight adult.

DRUG HISTORY Patients often present themselves to the community pharmacists in one of three ways: 1. with a self-diagnosed condition for which nonprescription drug therapy is sought, 2. with a newly diagnosed condition for which a drug has been prescribed, or 3. With a chronic condition that requires refill of a previously prescribed drug or the preparation of a new drug.

In the 1st and 2nd situations, the pharmacist must confirm the diagnosis using disease-specific questions. In the 3rd situation, the pharmacist uses the same type of questioning as in the above situations, moreover the pharmacist needs to evaluate whether therapeutic outcomes have been achieved. The pharmacist must evaluate the information collected during follow-up visits in the context of history and incorporate it into his/her assessment and pharmaceutical care plan. The goals of the therapeutic history are to obtain and assess the following information: 1. the specific prescription and nonprescription drugs the patient is taking ; nonprescription drugs include OTC drugs, vitamins and other dietary or nutritional supplements, recreational drugs, alcohol, cigarettes, phytochemicals, natural products, homeopathic preparations, and home remedies.

2. the intended purpose or indications for each of these medications, 3. how often, how much, and how the drugs are used, 4. how long the drugs have been taken or used, 5. are the drugs providing therapeutic benefit, 6. is the patient experiencing any adverse effects that could be caused by each of the drugs; The adverse effects include such as: a. idiosyncratic reactions, b.toxic effects, c. adverse effects 7. Are there any allergic reactions and any history of hypersensitivity or other severe reactions to drugs?

The information should be as specific as possible, including a description of the reaction, the treatment, and the date of its occurrence.

 P.J. has indicated that she is injecting insulin to treat her diabetes. What questions might be asked to evaluate P.J.s use of and response to insulin? The following types of questions when asked of P.J. should provide the pharmacist with information on PJs understanding about the use of and response to insulin.

The patients responses to the questions below will: 1. Allow a quick assessment of the patients knowledge of insulin and whether she is using it in away that is likely to result in blood glucose concentrations that are neither too high nor too low. 2. Provide the pharmacist with insight about the extent to which the patient has been involved in establishing and monitoring therapeutic outcomes.

Then, based on the information, the pharmacist can begin to formulate the patients educational needs.

Drug Identification and Use 1. What type of insulin do you use? 2. How many units of insulin do you use? 3. When do you inject your insulin in relation to meals? 4. Where do you inject your insulin? (Instead of the more judgmental question: Do you rotate your injection sites?) 5. Please show me how you usually prepare your insulin for injection (This question requires the patient to demonstrate a skill).

Assessment of Therapeutic Response 1. How do you evaluate your response to insulin? 2. What glucose levels are you aiming for? 3. How often and when during the day do you test your blood glucose concentration? 4. Do you have any blood glucose records that you could share with me? 5. Would you show me how you test your blood glucose concentration? 6. What is your understanding of the hemoglobin Atc blood test? 7. When was the last time you had this test done? 8. What were the results of the last hemoglobin Atc test?

Assessment of Adverse Effects 1. Do you ever experience reactions from low blood pressure? 2. What symptoms warn you of such a reaction? 3. When do these typically occur during the day? 4. How often do they occur? 5. What circumstances seem to make them occur more frequently

6. Examine injection sites.

SOCIAL HISTORY The social history is used to determine: 1. the patients occupation and lifestyle, 2. important family relationships or other support systems, 3. any particular circumstances (e.g., a disability or stresses) in her life that could influence the pharmaceutical care plan that is developed to achieve the agreed-on therapeutic outcome, 4. Attitudes, values, and feelings about health, illness, and treatment.

A patients occupation, lifestyle, and attitudes often can determine the success or failure of drug therapy.

Therefore, P.J.s nutritional history, her level of activity or exercise in a typical day or week, the family dynamics, and any particular stresses that may effect glucose control need to be documented and assessed. What questions might be asked of P.J. to gain this information?

Work Describe a typical work day and a typical weekend day Exercise Do you exercise? What type of exercise is it? How often, how long, and when during the day do you exercise? Do you change your meals or insulin when you exercise? If so, how?

Diet

 How many times per day do you usually eat? Describe your usual meal times. What do you usually eat for each of your main meals and snacks? Are you able to eat at the same time each day? What do you do if a meal is delayed or missed? Who cooks the meals at home? Does this person understand your dietary needs? How often do you eat meals in a restaurant? How do you order meals in a restaurant to maintain a proper diet for your diabetes?

Support Systems Do you live with anyone? What do they know about diabetes? How do they respond to the fact that you have diabetes? How do they help you with your diabetes management? Does it ever strain your relationship? What are the issues that seem to be the most troublesome?

Attitude

 How do you feel about having diabetes? What worries or bothers you the most about having diabetes?

SYSTEMATIC APPROACHES TO PATIENT THERAPY ASSESSMENT

Patient therapy assessment is the process whereby a pharmacist integrates his/her knowledge of medical and drug-related facts with information about a specific patients medical and social history to develop an optimal therapeutic plan for that patient. The pharmacist must decide which option is preferred when faced with multiple treatment options. When a treatment regimen has been prescribed that the pharmacist does not consider optimal, he/she must decide to either accept the plan or advocate for a change on the patients behalf.

Time constraints and the amount of patient information available in certain practice environments may dictate the level of assessment that can be undertaken and the need to intervene on the patients behalf should never be abdicated. At one extreme, simply accepting all difference of opinion without an intervention because of time constraints or fear of angering the prescriber is not acceptable. Implementing pharmaceutical care entails integrating, assessing, and applying the information from the patients record or database to the identification and solution of therapeutic problems. This requires an organized thought process for evaluating information. Therefore, a systematic approach is needed for analyzing a case history, setting priorities about which patients require more in-depth intervention, monitoring drug therapy, and communicating information to other health care providers in an organized and concise format.

PROBLEM-ORIENTED MEDICAL RECORD APPROACH

Organizing information according to medical problems (e.g., diseases) helps break down a complex situation (e.g., a patient with multiple medical problems requiring multiple drugs) into its individual parts. The medical community has long used a problemoriented medical record (POMR) or SOAP (subjective, objective, assessment, and plan) note to record information in the medical record or chart using a standardized format. Each medical problem is identified, listed sequentially, and assigned a number. Subjective data and objective data in support of each problem are delineated, an assessment is made, and a plan of action identified.

Elements of the Problem-Oriented Medical Record (POMR) Problem name Each problem is listed separately and given an identifying number. Problems may be a patient complaint (e.g., headache), a laboratory abnormality (e.g., hypokalemia), or a specific disease name if prior known. When monitoring previously described drug therapy, more than one drug-related problem may be considered: e.g., 1. noncompliance, 2. a suspected adverse drug reaction, or 3. drug interaction, or an inappropriate dose Under each problem name, the following information is identified. Subjective Information that explains or delineates the reason for the encounter.

Information that the patient reports concerning symptoms, treatments tried, medications used, and adverse effects encountered. These are considered non-reproducible data because the information is based on the patients interpretation and recall of past events.

Objective Information from physical examination, laboratory results, diagnostic tests, pill counts, and pharmacy profile information. Objective data are measurable and reproducible.

Assessment A brief, but complete description of the problem, including a conclusion or diagnosis that is supported logically by the above subjective and objective data.

The assessment should not include a problem or diagnosis that is not defined above.

Plan A detailed description of recommended or intended further: . Workup (laboratory, radiology, consultation), . Treatment (e.g., continued observation, physiotherapy, diet, medications, surgery), . Patient education (self-care, goals of therapy, medication use and monitoring), . Monitoring and follow-up relative to the above assessment.

Problem List

Problems are listed in order of importance and supported by the subjective and objective evidence gathered during the patient encounter. For the purpose of assessing a patients drug therapy, two categories of problems exist.

The first are medical problems. These are thought of in terms of a diagnosed disease, but they also may be symptom complex that is being evaluated, a preventive measure (e.g., contraception), or a cognitive problems (e.g., noncompliance). Problems should be identified based on the pharmacists level of understanding. The second type of problem refers to drug-related problems such as prescribing errors, dosing errors, adverse drug effects, compliance issues, and the need for medication counseling. Drug-related problems may be definite or possible.

The distinction between medical problems and drug-related problems sometimes is unclear, and considerable overlap exists. Medical problems can alter the selection of drugs or the manner in which drugs are dosed or administered.

Subjective and Objective Data P.N., a 28-year-old man, has a BP of 140/100 mmHg. What is the primary problem? What subjective and objective data support the problem, and What additional subjective and objective data are not provided but usually are needed to define this particular problem?

The primary problem is hypertension. Subjective No data Objective Patients age Gender BP of 140/100 mmHg Hypertension is often an asymptomatic disease, subjective complaints such as headache, tiredness or anxiety, shortness of breath (SOB), chest pain, and visual changes are usually absent. If long term complications such as rupturing of blood vessels in the eye, glomerular damage, or encephalopathy were present, subjective complaints might be blurring or loss of vision, fatigue, or confusion. Objective data would include: 1. a report by the physician on the findings of the chest examination (abnormal heart or lung sounds if secondary CHF has developed/terjadi penumpukan darah

dipembuluh kapiler paru sehingga di alveoli kenajiran air shg akan trjadi perubahan suara yg berubah2), 2. an ocular examination (e.g., presence of retinal hemorrhages), and 3. Laboratory data on renal function (BUN/urea dalam darah menurun, creatinine, or creatinine clearance).

D.L., a 36-year-old construction worker, tripped on a board at the construction site 2 days ago, sustaining an abrasion of his left shin. He presents to the ED(emergency departmen/UGD) with pain, redness, and swelling in the area of the injury. He is diagnosed as having cellulitis (infeksi kulit dibawah jaringan kulit dan terjadi peradangan). What is the primary problem?

What subjective and objective data support the problem? What additional subjective and objective data are not provided but usually are needed to define this particular problem? The primary problem is cellulites of the left leg. Subjective data: The subjective data is D.L.s description of how he injured his shin during his work as a construction worker and his current complaints of pain, redness, and swelling. The wound was possibly a dirty wound. The other data: - How he cleaned the wound. - Tetanus immunization within the past 10 years. Objective data: The wound is on the left shin. (kaki kiri) Additional data:

- The intensity of redness on a one-to four-plus scale. - The size of the inflamed area as described by an area of demarcation. - The circumference(bagian yang terkena infeksi) of his left shin compared with his right shin. - The presence or absence of pus and any lymphatic involvement. - His temperature. - White blood cell (WBC) count with differential. (jenis2 sel darah putih disebut granulosit spt netrofil, basofil, eus) - Any available blood culture and sensitivity data.

C.S., a 58-year-old woman, has had complaints of fatigue, ankle swelling, and SOB, especially when lying down, for the past week. Physical examination shows distended neck veins, bilateral rales, an S3 gallop rhythm, and lower extremity edema.

She is diagnosed as having CHF and is being treated with furosemide and digoxin. What is/are the primary problem(s)? What subjective and objective data support the problem? What additional subjective and objective data are not provided but are usually needed to define this particular problem? The primary problem is CHF. In this case, a second primary problem may be present. Current recommendations for the management of heart failure recommend using an ACE inhibitor before or concurrent with digoxin therapy. Thus a possible drug-related problem is the inappropriate choice of drug therapy (wrong drug).

The patient and/or prescriber should be consulted to ascertain whether an ACE inhibitor has been used previously, if any contraindications exist, or if possible adverse effects were encountered. Subjective data C.S. claims to be experiencing fatigue, ankle swelling, and SOB, especially when lying down. C.S. claims to have been taking furosemide and digoxin. An expanded description of the symptoms and of her medication use would be helpful.

Objective data The findings on physical examination and the enlarged heart on chest radiograph. The other objective findings that would help in her assessment would be: - the pulse rate - BP - Serum creatinine - Serum potassium concentration - Digoxin blood level

- A more thorough description of the rales on lung examination - Extent of neck vein distension - Degree of leg edema. Assessment The pharmacist should assess the acuity, severity, and importance of these problems. Then, pharmacist should identify all factors that could be causing or contributing to the problem. The assessment of the severity and acuity is important because the patient expects relief from the symptoms that are of particular concern at this time. When a possible drug-related problem is detected during follow-up or monitoring, the assessment also should include an evaluation of the potential severity of this problem. Plan

After the problem list is generated, subjective and objective data are reviewed, and the severity and acuity of the problems are assessed, the next step in the problem-oriented (SOAP) approach is to create a plan. The plan, at the minimum, should consist of a diagnostic plan and a pharmaceutical care plan that include patient education. DIAGNOSTIC PLAN The diagnostic plan could include further diagnostic tests, evaluation of drug-induced problems, or referral to another health care provider. The extent of diagnostic plan would differ with different specialists. For pharmacist, the diagnostic plan would have a more drug-induced component and would likely differ to the diagnostic plan of other practitioners. PHARMACEUTICAL CARE PLAN

Therapeutic Objectives The pharmaceutical care plan describes desired clinical outcomes or therapeutic objectives.

The desired clinical outcomes must: 1. be patient specific 2. be established in collaboration with the patient (When appropriate, with other members of the health care team) 3. be clearly defined and either measurable or observable 4. be realistic (what can be accomplished reasonably) 5. begin with interventions that are essential to the patients acute well-being

Examples of clinical outcomes or therapeutic objectives: 1. curing a disease (e.g., treatment of infection), 2. eliminating or reducing a patients symptoms (e.g., pain control),

3. arresting or slowing the disease process (e.g., lowering a patients cholesterol or BP to reduce the risk of coronary heart disease), 4. preventing an unwanted condition or disease (e.g., contraception, immunizations, prophylactic antibiotics, avoiding the complications of diabetes or hypertension), 5. Improving the quality of life.

Besides a positive outcome, there are other concurrent goals related to drug therapy: 1. avoidance of adverse effects, 2. convenience ( to improve compliance), and 3. Cost-effectiveness.

In a patient with multiple medical problems: 1. The pharmacist must consider the therapeutic objective for each problem separately, as well as in the aggregate.

2. Ideally, a single treatment that achieves the targeted clinical outcome of more than one problem concomitantly. 3. Care must be taken to ensure that the therapy given for one problem does not worsen another problem or create a new problem. 4. More than one therapeutic objective may be needed for each of the patients problems. 5. The ideal clinical outcome may have to be achieved through a series of intermediate stepwise goals. 6. In some situations, an intermediate goal may be that which is realistic within the context of the patients situation (Example, patient with peptic ulcer: a. the short-term goal is symptomatic relief, b.the intermediate goal is healing the ulcer, and c. The long-term goal is preventing recurrence of the disease).

The potential benefits always should be balanced against the potential risks of therapy. This is relevant when considering drug dosages. In some cases, higher-than-average dosages may be acceptable if the patient is not responding to usual dosages and has not been experiencing side effects.

The interventions necessary to achieve the specified clinical outcomes also are integral to the pharmaceutical care plan.

The examples of interventions in a pharmaceutical care plan: 1. re-instituting correct use of a prescription drug when it is being taken or used improperly; 2. educating and working with the patient to self diagnose, evaluate, and solve therapeutic problems;

3. instituting non-prescription drugs, no-drug therapies, administration aids, or monitoring tools; 4. recommending or prescribing prescription drugs; 5. reinforcing continuation of already prescribed drugs; 6. alerting physicians to potential drug-related problems that can be solved only through an alteration of the original prescription, these include: a. discontinuing the drug, b.prescribing an alternative drug, c. altering the dosage or route of the current drugs, d.Adding other drugs. 7. Referring the patient back to his/her primary care provider.

P.N., a 28-year-old man, has a BP of 140/100 mmHg.

What is the primary problem? What subjective and objective data support the problem, and What additional subjective and objective data are not provided but usually are needed to define this particular problem? What would be some therapeutic objectives or desired clinical outcomes of P.N.s treatment? The primary problem is hypertension. Subjective No data Objective Patients age Gender BP of 140/100 mmHg Hypertension is often an asymptomatic disease, subjective complaints such as headache, tiredness or anxiety, shortness of breath (SOB), chest pain, and visual changes are usually absent.

If long term complications such as rupturing of blood vessels in the eye, glomerular damage, or encephalopathy were present, subjective complaints might be blurring or loss of vision, fatigue, or confusion. Objective data would include: 1. a report by the physician on the findings of the chest examination (abnormal heart or lung sounds if secondary CHF has developed, 2. an ocular examination (e.g., presence of retinal hemorrhages), and 3. Laboratory data on renal function (BUN, creatinine, or creatinine clearance).

Therapeutic objectives/Clinical outcomes Eradicating or curing the disease is not a realistic goal for hypertension. Symptomatic control also is no relevant BP often is an asymptomatic disease.

The therapeutic plan would be to control the BP, which is to achieve a diastolic BP of <90 mmHg but >65 mmHg within the next 3 months. This objective: 1. is measurable, 2. has a time line, and 3. hopefully is realistic, 4. addresses efficacy and side effect, 5. In short-term objective, is to be able to explain the long-term risks of untreated hypertension and the importance of complying with the treatment. The pharmacists interventions: 1. to educate the patient 2. assess drug refill patterns 3. measure the patients BP The long-term therapeutic objective: Prevent the long-term complications of hypertension such as kidney damage, loss of eye damage, and the development of CHF or other cardiovascular complications

 D.L., a 36-year-old construction worker, tripped on a board at the construction site 2 days ago, sustaining an abrasion of his left shin. He presents to the ED with pain, redness, and swelling in the area of the injury. He is diagnosed as having cellulitis. What is the primary problem? What subjective and objective data support the problem? What additional subjective and objective data are not provided but usually are needed to define this particular problem? What would be some therapeutic objectives or desired clinical outcomes of his treatment?

Pharmaceutical care process for D.L

The primary problem is cellulites of the left leg. Subjective data: The subjective data is D.L.s description of how he injured his shin during his work as a construction worker and his current complaints of pain, redness, and swelling. The wound was possibly a dirty wound. The other data: - How he cleaned the wound. - Tetanus immunization within the past 10 years. Objective data: The wound is on the left shin. Additional data: - The intensity of redness on a one-to four-plus scale. - The size of the inflamed area as described by an area of demarcation. - The circumference of his left shin compared with his right shin.

- The presence or absence of pus and any lymphatic involvement. - His temperature. - White blood cell (WBC) count with differential. - Any available blood culture and sensitivity data.

The therapeutic objectives or desired clinical outcomes for D.L.: 1. to provide symptomatic relief, 2. to eradicate the infection, 3. to prevent spread of the infection to the adjacent tissues The most likely causative organisms for cellulites are streptococci or staphylococci. The clinical outcome of eradication the infection means: 1. to eradicate a probable streptococcal or staphylococcal cellulites,

2. to prevent bacteremia and spread to lymphatics, and 3. To reduce pain and swelling. This outcome should be within a specific time. In this case, the inclusion of the type of infection and probable organisms helps define the antibiotic of choice (e.g., a penicillinase - resistant penicillin or a first-generation cephalosporin. Culture and sensitivity data which is specific for the patient should be obtained when available. The pharmacist should ask the patient about possible allergies to penicillins or cephalosporins. The desired clinical outcomes should imply: 1. to avoid side effects, and 2. To prescribe a regimen that is convenient and cost-effective. The education of the patient is an intervention that usually helps patients and pharmacists achieve their mutually developed therapeutic objectives.

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C.S., a 58-year-old woman, has had complaints of fatigue, ankle swelling, and SOB, especially when lying down, for the past week. Physical examination shows distended neck veins, bilateral rales, an S3 gallop rhythm, and lower extremity edema. She is diagnosed as having CHF and is being treated with furosemide and digoxin. What is/are the primary problem(s)? What subjective and objective data support the problem? What additional subjective and objective data are not provided but are usually needed to define this particular problem? What would be the therapeutic objective in this case?

The therapeutic objective for this patient: 1. to provide symptomatic relief of CHF, including: a. increased exercise capacity, b.decreased SOB, and c. Reduced ankle swelling. 2. The long-term objective is to prolong the patients survival. The specificity of the goal is determined by the pharmacists knowledge of the pathophysiology, signs and symptoms of CHF, and the pharmacists experience in treating such patient. Other goals: 1. minimize toxicity of digoxin, 2. strive for a convenient, and 3. Cost-effective regimen. Finally, it must be decided whether an ACE inhibitor is indicated, and if so, which drug and at what dosage.

PATIENT EDUCATION PLAN

Educating the patient to better understanding his/her medical problem(s) and treatment also is an implied goal of all treatment plans. The level of teaching has to be tailored to the patients: 1. educational background, 2. willingness to learn, 3. General state of health and mind. The patient should be taught the knowledge and skills needed to achieve and evaluate his/her therapeutic outcome. The patient education plan emphasizes the need for patients to follow their prescribed treatment regimens.

ILLUSTRATION OF SOAP
Putri Jenaka (P.J.), a 45-year-old woman of normal height and weight, states that she has diabetes.

What questions might be the pharmacist asks of P.J. to determine whether type 1 or type 2 disease should be documented in her medical history? P.J. has indicated that she is injecting insulin to treat her diabetes. What questions might be asked to evaluate P.J.s use of and response to insulin? A patients occupation, lifestyle, and attitudes often can determine the success or failure of drug therapy. Therefore, P.J.s nutritional history, her level of activity or exercise in a typical day or week, the family dynamics, and any particular stresses that may effect glucose control need to be documented and assessed. What questions might be asked of P.J. to gain this information?

Based on the data about P.J., the pharmacist believes that P.J. is experiencing frequent hypoglycemic reactions.

What SOAP note could be developed for P.J.? A SOAP note illustrates the importance of integrating the patients medical, therapeutic, and social history into the design of a pharmaceutical care plan.

Problem 1:
Patient has been experiencing frequent hypoglycemia reactions. (The conditions may result from hypoglycemia are weakness, headache, hunger, problems with vision, loss of muscle coordination, anxiety, personality changes, and, if untreated, delirium, coma, and death. The treatment is the giving of sugar in orange juice by mouth if the person is conscious or through the veins if the person is unconscious) SUBJECTIVE:

Patient reports episodes characterized by severe hunger, tremors, and profuse sweating that are relieved by orange juice. Episodes occur twice weekly, generally in the late afternoon. Patient often skips lunch to exercise. Patient states that she uses 30 U of NPH insulin every morning mixed with 30 U of regular insulin. (NPH (neutral protamine Hagedorn or isophane) insulin is an intermediate- acting insulin whose onset of action is delayed by combining two parts soluble crystalline insulin with one part protamine zinc insulin). She claims to never miss a dose and takes her insulin at 8 AM each day. OBJECTIVE: Occasional blood glucose values of 30 to 60 mg/dL in the late afternoon, often followed by values > 300 mg/dL before dinner and at bedtime.

ASSESSMENT: Total daily dose of insulin is high (1.2 U/kg). Morning dose of NPH insulin may be excessive. She may require multiple daily injections of insulin. Carbohydrate intake and exercise patterns are erratic. Treatment of type 2 diabetes with insulin When the combination of metformin, sulfonylurea, and a thiazolidinedione fail and type 2 patients require insulin, various regimens may be effective. Some patients with type 2 diabetes enough residual insulin secretion persists to allow a single morning injection of 25-30 units of NPH or lente insulin to replace their deficient insulin secretion. A convenient regimen includes split doses of a fixed 70:30 mixture of NPH: regular insulin, which can be started as 20 units before breakfast and 15 units before dinner and increased appropriately depending on target blood glucose at 7:00 AM and 5:00 PM. Acceptable levels of glycemic control:

Blood glucose levels of 90-130 mg/dL before meals and after an overnight fast, and levels no higher than 180 mg/dL for 1 hour after meals and 150 mg/dL for 2 hours after meals are considered acceptable

PLAN: Therapeutic objectives: Initially, fasting blood glucose <140 mg/dL, postprandial blood glucose < 180 mg/dL, all blood glucose concentrations > 70 mg/dL. No symptoms of hypoglycemia such as those noted above under SUBJECTIVE. Patient needs to eat more regularly, and carbohydrate intake to be distributed appropriately throughout the day. Patient should be able to predict time of peak NPH insulin activity and the relationship between carbohydrate intake and insulin dosage.

Patient and family members can describe symptoms of hypoglycemia and its treatment. Patient can make appropriate insulin and dietary adjustment for exercise. Patient can demonstrate correct blood glucose testing procedure; bring in records of blood glucose test results that reflect appropriate testing frequency.

Education Plan: Teach patient and key family members about dangers of hypoglycemia, symptoms of hypoglycemia, relationship between insulin action and food intake (insulin pharmacodynamics), and treatment of hypoglycemia. Ask patient to demonstrate blood glucose testing technique. Correct as necessary. Institute more frequent of glucose testing (before meals and at bedtime) to document the patterns of glucose response to insulin therapy

Instruct patient to perform additional tests when she experiences symptoms of hypoglycemia to verify reaction. Educate patient about effect of exercise on blood glucose. Refer to dietitian. Objective is to emphasize importance of eating regularly and spreading out carbohydrate content of meals. Review and evaluate patient glucose records, signs, symptoms, and dietary and exercise history weekly. Help patient interpret and adjust insulin dosages accordingly until target is achieved. Then evaluate quarterly. Call and write primary care provider regarding hypoglycemic reactions and insulin dosage and regimen. Recommend how to decrease and reallocate doses based on glucose test results.

This SOAP note demonstrates that pharmaceutical care is an iterative process with the potential for a high level of sophistication and complexity. Each time the pharmacist interacts with the patient, the pharmacist monitors and evaluates the patients progress toward the designated therapeutic outcome or target. This, along with any new information, is used to redefine or refine the problem list, clarify the assessment, or modify the therapeutic targets or plan. Thus, a continuous readjustment occurs with the overall goal of improving therapeutic outcomes and the patients quality of life. ====Prof. Dr. Suwaldi Martodihardjo, M.Sc., Apt==== ====Faculty of Pharmacy Gadjah Mada University=== =========Jogjakarta==================== ====

AN EXAMPLE OF PATIENT PRESENTATION FOR PHARMACEUTICAL CARE Chief Complaint I have this constant cough thats getting worse, and I have no energy History of Present Illness (HPI) Big Boy (BB) is a 50 year-old man who presents to the Medicine Clinic complaining of a 1-month history of a persistent cough that has become productive over the past 2 weeks. He also complains of malaise, fever, night sweats, and a 9.1 kg weight loss over the past 2 months. Past Medical History (PMH) Seizure disorder since age 10 HTN-5 years Family History (FH) His mother and father died in an MVA 10 years ago; one brother, age 37, is HIV (+) and lives with the patient; one sister, age 47, is alive and has no known medical problems.

Social History (SH) Patient is single, no children. He worked as an aide in a local nursing home but was laid off 6 weeks ago when the home was purchased by a regional chain. He denies smoking or IV drug use. He had a 20-year history of alcohol abuse, but has been sober for 10 years. His brothers HIV infection, attributed to IV drug abuse, is in the early stages with a CD4 count of 280 and a low viral load. Medications (Meds) Phenytoin 300 mg p.o. QHS Hydrochlorothiazide 25 mg p.o. QD Patient reports that he tries to be compliant with his therapies and takes them regularly except when he is unable to get his refills; over the past 2 months, he has gone 3 or 4 days without medication. Allergies (All) Not known drug allergies (NKDA) Review of Systems (ROS)

Unremarkable except for complaints of recurrent headaches and intermittent abdominal pain; No seizures for 8 months Physical Examination (PE) General appearance (Gen) Thin, emaciated African American man who appears older than stated age; Appears fatigued, but otherwise in no acute (or apparent) distress (NAD); Vital signs (VS) BP 138/88; P 84; RR 16; Temp 38,3oC; Wt 51 kg Chest Diffuse rhonchi in upper lobes, decreased breath sounds on left, with pleural rub. Skin Cool to touch; multiple bruises on extremities; moles on trunk. Cardiovascular (CV) RRR; no m/r/g Labs

AST 72 IU/L ALT 56 IU/L Etc. Other Consent for HIV testing obtained Chest X-Ray Profound bilateral upper lobe infiltrates with questionable cavitation on left, bases spared; small left pneumothorax with effusion. CT Chest Small posterior peritracheal and hilar nodes; left pleural thickening and small pneumothorax; Cavity (3-4 cm) in left posterior segment, no air fluid level. Clinical Course The patient was admitted and placed on respiratory isolation. Three separate sputum Gram stain specimens were reported to contain 3+ AFB. An intermediate-strength PPD tuberculin skin test (Mantoux method) was placed. Candida and mumps were used as controls. Sputum

samples were sent for AFB, fungi, and bacteria. After 48 hrs, the PPD skin test was read as a 12mm area of induration. Assessment Active pulmonary tuberculosis

Questions
Problem Identification 1. a. Create a list of the patients drug-related problems. b. Which signs, symptoms, and other findings are consistent with active TB infection? c. What factors place this patient at increased risk for acquiring TB? Desired Outcome 2. What are the goals of therapy for this patient with active TB?

Therapeutic Alternatives 3. a. What non-drug therapies might be useful in this patient? b. What drug therapies are available for the treatment of active TB? c. What economic and social considerations are applicable to this patient? Optimal Plan 4. a. What drug, dosage form, dose, schedule, and duration of therapy are best for this patient? b. What alternatives to daily administration of medicines exist? Outcome Evaluation 5. Which clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects? Patient Counseling 6. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?

Clinical Course The patient is treated with the regimen you recommended under respiratory isolation in the hospital. The results of his HIV test were negative. After 10 days, his presenting symptoms have improved, and three consecutive sputum specimens have been negative for AFB. Because he had three negative smears, he was removed from respiratory isolation and subsequently discharged to home. After 6 weeks, the results of these initial cultures are available. Mycobacterium tuberculosis is present, and the sensitivity report indicates INH-resistant organisms. The organism is sensitive to all other agents. Follow-Up Question 1. How should the presence of INH resistance influence the drug therapy? 2. After 3 months of therapy, an increase in the patients AST and ALT are noted (AST 160 IU/L; ALT 190 IU/L). Other liver enzymes and total bilirubin are normal. The patient reports no new complaints. What changes would you

make to the current therapy and monitoring plan? 3. What potential drug interactions should be evaluated? How should they be managed? 4. How should other close contacts of the patient, including the brother, be evaluated and treated (considering that the patient has INH-resistant organisms)? Clinical Pearl All patients receiving treatment for active TB should be considered for directly observed therapy (DOT). With adequate drug therapy for TB, nearly all patients with drug-susceptible organisms will become bacteriologically negative, recover, and remain well. For people who are candidates for serial tuberculin skin test (e.g. health care workers) an initial two-step test should be considered. With this strategy, an initial negative skin test is repeated in 2 weeks to prevent confusion in interpreting results in subsequent years.

For HIV-positive patients, rifabutin can be substituted for rifampicin to reduce the potential for drug interactions.