Clinical Pharmacy

Ruanee G. Escala, RPh, PharmD | Prelim Coverage

PHARMACEUTICAL CARE
Topic Outline:
● Introduction to Clinical Pharmacy
● Pharmaceutical Care • It is the responsible provision of drug therapy for the
purpose of achieving definite outcomes that improves
a patient’s quality of life.
INTRODUCTION TO CLINICAL PHARMACY
• A patient-centered practice in which the practitioner
assumes responsibility for a patient’s drug-related
Clinical Pharmacy
needs and is held accountable for this commitment.
• Branch of pharmacy where the pharmacists provide
• Major functions of Pharmaceutical Care:
patient care that optimizes the use of medications and
o Identifying potential and actual drug-related
promotes health, wellness, and disease prevention.
problems
• A practice in which the pharmacy utilizes his
o Resolving actual drug-related problems
professional judgment in the application of
o Preventing potential drug-related problems
pharmaceutical sciences to foster the safe and
• Expected outcomes of Pharmaceutical Care
appropriate use of drugs, in or by patients, while
o Preventing disease and symptoms
working with members of the health care team.
o Arresting and slowing the disease process
• Health science specialty whose responsibility is to
o Cure a disease.
assure the safe and appropriate use of drugs in
o Elimination or reduction of patient’s
patients through the application of specialized
symptoms
knowledge and functions in patient care.
PHARMACEUTICAL CARE PROCESS
CLINICAL PHARMACIST
• Assessment
• Interacts with the healthcare team.
• Care Plan
• Interview and assess patient information.
• Evaluate of outcome
• Design and implement a therapeutic plan.
• Make therapeutic recommendation.
Assessment
• Monitor patient response to drug therapy.
• Assess the patient for drug-related problems.
• Monitor adverse drug reactions.
• Determine whether drug-related problems are being
• Provide drug information. treated.
• Determine whether current drug therapy is
CLINICAL PHARMACY SETTINGS
appropriate.
• Determine whether additional drug therapy is needed.
• Hospitals
• Determine if any of the drug-related problems may
• Community pharmacies have been caused by medication.
• Nursing homes
• Home-based care services Care Plan
• Clinics • Approach normal physiology
• Any other setting where medicines are prescribed and • Slow progression of disease
used. • Alleviate symptoms
• Prevent adverse effects
Application of Different Scientific Principles
• Control medication costs
• Pharmacology
• Educate the patient about his/her medication
• Toxicology
• Therapeutics Evaluate of outcome
• Clinical pharmacokinetics • Specify patient’s progress
• Pharmacogenomics • Monitor potential adverse drug reactions
• Pharmacoeconomics • Determine desired end points for each parameter and
the frequency of monitoring

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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

Medicines Optimization Patient Chart

• Aims to ensure that the right patients get the right • Also known as Medical Record
choice of medicine at the right time. • Notes by Health Care Professionals
• The purpose is to help patients take their medicines • Communication tool
appropriately and by doing so, avoid unnecessary • Source of Info, research
treatment, improve safety and outcomes, and reduce • Quality Assurance Evaluation
wastage.
Patient Medical Chart (PMC)
Rational Drug Use • Contains all significant clinical information which
• Requires that patients receive medications enables the physician to give effective continuing care
appropriate to their clinical needs, in doses that meet to the patient
their own individual requirements for an adequate • Used as a basis for drug therapy plan for patient
period of time, and at the lowest cost to them and
their community. PARTS OF PATIENT MEDICALCHART
• Right - drug, disease, dose, dosage form, dosing
schedule, route, cost and patient I. Patients Data Sheet
• Patient Demographics (Identification and sociological
Essential Clinical Knowledge data)
• Diagnostic testing • Admission and final diagnosis
• Disease • Condition upon discharge (discharge summary,
• Drug Therapy autopsy)
• Non-drug Therapy
II. Consent Form
Essential Clinical Skills • Permission or approval given by patient for
• Communication admission, testing, procedure and access to health
• Drug Information Provision related or personal information
• Therapeutic planning • Consent must be given freely and without coercion
• Patient monitoring and physical assessment
III. History
CLINICAL PHARMACY SERVICES • Chief Complaint (CC) – reason/s the patient is
seeking medical care or attention
Medication History Taking and Documentation • History of Present Illness (HPI) – Narrative, current
medical problem
Patient Medication Profile • Past Medical History (PMH) – Current and previous
• Written summary of all the medicines taken regularly, patient problems, unrelated to present illness.
including over the counter and complementary • Family History – Medical history of patient’s first-
medicines degree relatives
• Assist to understand and manage medicines by • Social History – Use of tobacco, alcohol, illicit drugs,
informing how, why and when to take medicine. computing of pack years, occupation, marital status,
sexual history, living conditions
Medication Reconciliation Process • Review of Systems (ROS) – summary of patient
• Medication reconciliation - is the process of creating complaints not included in HPI
the most accurate list possible of all medications a
patient is taking- including drug name, dosage, Computation for pack years
frequency, and route – and comparing that the list • Smoking Pack Year =
against the physician’s admission, transfer, and/or !"#$%& () *+,-.* /%& 012
discharge orders, with the goal of providing correct 34 *+,-.*
x years of smoking
medications. • 1 pack of cigarettes = 20 cigarette sticks
• The ideal medication reconciliation process begins
with conducting a thorough patient medication
interview and obtaining an accurate list of all current
medications from the patient/and or caregiver.
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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

Palpation
IV. Physical Examination • The use of the hand to feel skin texture and contour,
• Short description and masses below the surface
• Vital Signs (body temperature, pulse rate, respiration • Temperature and vibration can also be detected by
rate, blood pressure) palpation
• Systemic examination • Light palpation - to check muscles tone and assess
for tenderness
PHYSICAL ASSESSMENT TECHNIQUES • Deep palpation - to identify abdominal organs and
abdominal masses.
Vital Signs • Also for hard-to-reach organs (liver, spleen, kidney)
• Body temperature (37 ± 0.5 C
̊ )
o Can be measure in: Percussion
§ 1. Oral - most accessible and • Is used to elicit a sound which reflects the density of
accurate underlying tissue and structures
§ 2. Rectal - accurate but • Tapping the body directly or tapping a finger placed
uncomfortable on the body
§ 3. Axillary - least accurate, most • Determine the size and shape of underlying structures
safe by establishing their borders and indicates if tissue is
§ 4. Tympanic air-filled, fluid filled, or solid
o Abnormal Findings: • Dull percussive sounds - indicative of abnormal lung
§ Hyperthermia density; presence of a solid mass under the surface
§ Hypothermia • Hyperresonance on percussion - indicates too much
air is present within the lung tissue
• Pulse rate (60-100 beats/min)
• Radial pulse - most easily accessible Auscultation
• Femoral or carotid pulse - palpitate in emergency • Listening to sounds produced by the body originating
cases. in internal organs
o Abnormal findings: • Direct auscultation - use of unaided air
§ Irregular pulse rhythm – • Indirect auscultation - using stethoscope.
bradycardia, tachycardia o General sequence: Ins- Pal-Per-Aus
o Abdominal assessment: Ins-Aus-Per-Pal
• Respiratory rate (16-20 breaths/min)
o Abnormal findings: V. Physician’s Order Sheet
§ Prolonged expiration suggesting • Doctor’s progress notes – are located in the left part,
narrowing in bronchioles (asthma) written in SOAP format
§ Sounds: wheezing or stridor • Doctor’s orders - are written at the right part directly
o Apnea - no breathing opposite the progress notes
o Bradypnea, tachypnea
VI. Consultation, Examination and Findings
• Blood pressure (<120 and <80 mmHg) VII. Graphic Chart
o Abnormal findings: VIII. Fluid input and output record
§ Hypertension
§ Cardiac disease IX. Medication administration record - accomplished by the
§ Orthostatic hypotension bedsides nurses every shift
§ Venous congestion or hypertension
X. Multidisciplinary Progress Notes - used by all other
IPPA medical professionals except for physicians for documentation.

Inspection XI. Laboratory results

• Visual examination of the patient
• It includes the 5 senses

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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

DOCUMENTATION Non-prescription of OTC drugs

• Over-the-counter drugs
Documentation - means by which healthcare professionals • Dispensed without prescription and for prevention of
communicate with one another symptomatic relief of minor or self-limiting illness

SOAP Parts of a Prescription

• S - Subjective: Information from the patient’s • Name of the patient and address
statement • Date when the prescription was written
• - Objective: The observations of the physician during • Superscription - Rx sign, Recipe means take thou;
the examination and the laboratory results direct order
• A - Assessment: The impression of the patient’s • Inscription - list of ingredients and their respective
problem that leads to diagnosis quantities
• P - Plan: The treatment plan to correct the illness or • Subscription - direction to the pharmacist
problem, there should be a plan will follow the same • Transcription - direction to the patient
numerical format as assessment • Name, Address, PTR # of prescriber

Medication Order Review Incorrect Prescriptions (DOH AO no. 62)

1. Erroneous
• Medication order review by pharmacists is a multistep 2. Violative
process in which pharmacists evaluate orders 3. Impossible
(prescriptions) for safety, efficacy, and
appropriateness by examining drug-and patient Erroneous
related factors (drug interactions, adverse drug • Brand name preceded Generic Name
interactions, medication errors) • Generic name is in parenthesis
• Brand name is not in parenthesis
• What to do?
o Fill the prescription
o Keep the prescription
o Report to nearest DOH

Violative
• Generic name is not written
• Brand name is written, Generic name is not legible
• Terms that hinder generic dispensing
• What to do?
o Do not fill and keep prescription
• o Report to nearest DOH
o Ask patient to return to prescriber to get
PRESCRIPTION proper prescription

• A written order for medication issued by a licensed Impossible

physician, dentist, veterinarian, or only licensed • Only generic name is not written (not legible)
medical practitioner. • Generic name doesn’t correspond to brand name
• Both are written but not legible
Prescription or Ethical drugs
• What to do?
• Prescribed by a doctor
o Do not fill and keep prescriber
• Bought at a pharmacy o Report to nearest DOH
• Prescribed for and intended to be used by one person o Ask the patient to return
• Regulated by FDA through the New Drug Application
(NDA)

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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

Yellow Prescription Drug Information Services

• Partial filling is allowed
• Not all dangerous drugs require a yellow prescription 1. Primary Source - Provide the most current information
for it to be dispensed (especially all tablets except • Examples: Journal articles
oxycodone and morphine) o a. Journal of Pharmacy & Pharmacology
• Brand name is not required in prescribing the drug o b. New England Journal of Medicine

Prohibited drug 2. Secondary Source

• Opium and its active components and derivatives • For quick and selective screening of the primary
(heroin and morphine) literature.
• Coca leaf and its derivatives (cocaine; alpha and beta • Examples: Abstracting & Indexing Services
eucaine) o a. Index Medicus
• Hallucinogenic drugs (mescaline, lysergic and o b. DrugDex
diethylamide, Indian hemp and its derivatives)
• And other drugs, whether natural or synthetic with the 3. Tertiary Sources
physiologic effects of a narcotic drug • Provide easy and convenient access; information may
be outdated.
Regulated drug • Examples: Textbooks
• Self-inducing sedatives (secobarbital, phenobarbital, o a. Harrison’s Principles of Internal Medicine
barbital, amobarbital and any other drug which and Applied Therapeutics
contains a salt or derivative of a salt or barbituric acid)
• Amphetamine salts and isomers (Benzedrine or DRUG DEVELOPMENT
Dexedrine)
• Hypnotic drugs, such as methaqualone or any other 1. Drug Discovery & Screening (2 years)
compound producing similar physiologic effects. • Discovery of lead compounds
• Screening of activity
Evidence-Based Medicine (EBM) • Chemical design
• Synthesis & characterization
• The conscientious, explicit and judicious use of
current best evidence in making decisions about the 2. Pre-clinical Studies
care of the individual patient. • Tested on animals
• It means integrating individual clinical expertise with • Efficacy, safety, toxicity, mechanism
the best available external clinical from systematic (pharmacokinetics and pharmacodynamics)
research.
3. Investigational New Drug (IND)
EBM Integrated Components • Pharmaceutical company obtains permission to start
human clinical trials
1. Clinical Expertise - Clinician’s cumulated experience, • Drug is not yet been approved for general use by the
education and clinical skills. FDA
2. Patient values - personal and unique concerns,
expectation and values 4. Clinical Trials (4-5 years)
3. Best evidence - clinically relevant research with sound • Tested on animals
methodology • 3 Phases:
o PHASE I: Screening for safety
Hierarchy of Evidence § Initial assessment of safety,
• Systematic reviews tolerance, pharmacokinetics and
• Non-randomized clinical trials pharmacodynamics.
• Randomized clinical trials § Healthy human volunteers (20-100)
• Observational studies o PHASE II: Establishing the Test Protocol
• Expert options § Initial assessment in the target
population
§ IIa - identification of doses
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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

§ IIb - assess and efficacy - well What to do with DTP’s?

controlled narrowly-defined • Identify
population (100-300) - double- • Resolve
blinded randomized clinical trials • Prevent
o PHASE III: Final Testing
§ confirmation of doses Medication Error
§ expanded tolerability profile. • Any preventable event that may lead to inappropriate
§ multicenter multisite; benefit-risk medication use or cause harm to the patient while the
ratio medication is in control of a health care professional,
§ more-varied population patient or consumer.
§ double-blinded randomized clinical
trials Potential Error
• This is a mistake in prescribing, dispensing, or
5. New Drug Application (NDA) planned medication administration that is detected
§ Includes enough information for the FDA to determine and corrected through intervention (by another
whether the new drug is safe and effective, drug’s healthcare provider or patient) before actual
benefits outweighs the risk, whether the proposed medication administration.
drug label is appropriate, and whether the drug
manufacturing standards are adequate. Omission error
• The failure to administer an ordered dose to a patient
6. Marketing before the next scheduled dose, if any.

PHASE 4: Post-marketing Prescribing Error

• wider population • This includes incorrect drug selection, dose, dosage
• detect previously unknown adverse effects and drug form, quantity, route, concentration, rate of
interactions administration, or instructions for use of a drug
• different formulation, dosage, mode of administration product ordered or authorized by physician.
• It also includes illegible prescriptions or medication
PATENT (Last for 20 years) orders that reach the patient.
• When patent expires, generic counterparts become
available Improper Dose Error
• Administration to the patient of a dose that is greater
Phases of Product Development than or less than the amount ordered by the
• Pre-clinical stage - Animal studies prescriber or administration of duplicate doses to the
• Phase 1 - Assess safety in healthy human volunteers patient, i.e., one or more dosage units in addition to
• Phase 2 - Evaluate effectiveness of a drugs in those that were ordered
patients with disease or condition
• Phase 3 - Large-scale multicenter clinical studies Wrong Drug Preparation Error
• Phase 4 - Post-marketing studies • Drug product incorrectly formulated or manipulated
before administration
DRUG THERAPY PROBLEMS
PATIENT COUNSELING
Drug Therapy Problems
• Unnecessary Drug Therapy EFFECTIVE PATIENT COUNSELING
• Wrong Drug • Pharmacist introduces self.
• Dose Too Low • Identifies patient
• Dose Too High • Explain purpose
• Adverse Drug Reactions • Ask what did the physician say
• Patient Non-Adherence • Ask the chief complaint
• Need for Additional Drug • Tell the name, indication and route of administration
• Dose regimen

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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

• Onset of Action Communication Skills

• Duration of therapy
• Benefits Active listening and Attending Skills
• ADR’s Þ Stop talking
• Precautions, warnings and contraindications Þ Get rid of distractions
• Non-pharmacologic interventions Þ React to ideas (not to the person)
• Drug interactions Þ React non-verbal messages
• Storage recommendations Þ Listen to how something is said
• Missed dose Þ Provide feedback to clarify any message
• Repeat
• Additional Concerns Emphatic Responding Skills
• Check medicine Þ Reflecting - concentrating on the emotional meaning
Þ Paraphrasing - conveying the essence of what was
Patient Medication Counseling said
According to ASHP: provision of oral and written information Þ Focusing - getting back to the topic of the
about drugs and other health-related information to a patient or conversation
his/her representatives during dispensing process or hospital
stays.
Interviewing Skills
Questions: Þ Ask open questions
Þ Ask closed questions
CLOSE Þ Check if the patient has understood or requires more
• Narrow information
• Used when a direct answer is needed Þ Avoid suggesting during data-gathering phase
• Answerable by yes or no Þ Provide a balance of questions
• Chronic use à choppy interview Þ Do not jump into conclusion
• Decreased quality and quantity of information Þ Keep goals of the conversation in mind
• Decreased opportunity to develop rapport with the Þ Avoid shifting from one topic to another until one is
patient finished
Þ Maintain objectivity
OPEN
• Wide-ranging Influencing Skills
• Not directly answerable by use or no Þ Give relevant advice
• Chronic use à lengthy interview Þ Make good suggestions
• Increased quality and quantity of information Þ Share correct information
• Can develop rapport, assess disposition of the patient Þ Summarize main points of information given
Þ Emphasize key points with “this is important”
LEADING or LOADED Þ Supplement spoken word with written instruction
• Usually closed Þ Give reasons for key advice
• Contain their own answer Þ Check for accuracy of patient’s understanding
• Imply judgment on the patient Þ Give definite, concrete, explicit instruction
• Not fruitful
• Must be avoided Stages in Patient Counselling

DOUBLE OR MULTIPLE I. Medication Information Transfer

• Presents the patient with 2 or more inquiries at the II. Medication Information Exchange
same time III. Medication Education
IV. Medication Counseling
• Traps the patient in a barrage of questions
• Patient gets confused, irritated

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Clinical Pharmacy
Ruanee G. Escala, RPh, PharmD | Prelim Coverage

Forms of Nonverbal Communications Autonomy

Þ Speech related • A form of personal liberty, where the individual is free
Þ Non-verbal behavior to choose and implements one’s own decisions, free
Þ Aspects of personal appearance from deceit, duress constraint or coercion
Þ Sign language • Obligation to respect patients as individual
Þ Symbols • Honor their preferences in medical care
Þ Written word
Þ Use of body Nonmaleficence
Þ Use of media • Do no harm
• It benefits outweigh the risks patients may make an
Elements of Communication Process informed decision to proceed

DRUG EDUCATION APPROACH BY PHARMACIST Beneficence

INVOLVES: • Acts of mercy and charity or any action that benefits
Þ Counseling another or apply measures for the benefit of the sick
Þ Assessment
Þ Reinforcement Confidentiality
Þ Evaluation • An important aspect of trust that patients place in
health care professionals.
Terms: • Respect patient privacy and autonomy
1. Proxemics - involves the structure and use of
space important in patient counseling
2. Kinesis - involves the manner of using the parts of
the body
3. Counseling- a skilled and principled use of
relationships to facilitate self-knowledge, emotional
acceptance and growth and the optimal development
of personal resource.
4. Empathy - the ability to see the world from the point
of view of another person, through their frame of
reference; through their conceptual and emotional
spectacles

Pharmaceutical Care Plan

1. Assessment - a review of the medical conditions and

symptoms to determine the need for drug therapy
2. Plan - a decision of an appropriate drug therapy based on
the assessment of the patient
3. Monitoring – a review of the outcomes of drug therapy
(goals and endpoints) to determine if the patient is obtaining
the desired outcomes

Pharmacy Ethics

Ethics
• Science of morality
• Refers to the moral principles of practice.
• Study of human acts or conduct from a moral
perspective as to whether they are good or they are
bad.

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