CPT 3rd Care Plan

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Pharmaceutical Care Plan

Patient name: NHS number: DOB:

Priority Medical problem Care issue Proposed action Evidence

COPD COPD condition is worsening- Change patient treatment to


breathlessness, failure to complete triple therapy inhaler NHS Grampian
sentences, flushed and cough producing [LABA/LAMA/ICS] to improve respiratory MCN
green purulent sputum ACUTE complacence as there is only one
EXACERBATION technique he will need to learn NICE CKS
and remember CORTICOSTEROIDS-
Patient receiving medicines The patient is suitable to start INHALED
appropriately or cannot use inhaler triple therapy as is
adequately => poor compliance - 35 years old NICE NG115 2018
3 diff inhalers with 3 diff techniques so - has a FEV1 value of less
might be very confusing than 50%
- Has had 3 exacerbations
Salbutamol 100mcg 2 puffs PRN [SABA]- - Has an MRC score of 3
patient has relayed he struggles to hold NICE CKS ACUTE
for 10 seconds after, he’s been High dose of short term use EXACERBATION OF
requiring it a lot more often and not steroids PREDNISOLONE is COPD
noticed it making any impact necessary to relive the immune
response and inflammation
Relvar Ellipta 184/22 1 puff OD [ICS]- that’s causing his exacerbation
Patient has relayed it is difficult to tasks
a full breath in Given oral prednisolone 30mg

© Robert Gordon University, Aberdeen


once daily for 5 days upon
Tiotropium 18mcg handihaler 1 pudding admission
OD [LAMA]- Take in morning and with food
Patient relays it is hard to breathe in the
powder As the course required is less
than 3 weeks, the prednisolone
does not need to be tapered off

Prescribe upon hospital release


Trelegy ellipta 92/22/55 mcg 1
puff OD *dpi
OR
Trimbow 87/5/9 mcg 2 puffs
BD *pMDI
With a spacer

Leaning more to pMDI as more


suitable for this patient due to
the poor inspiration strength
FEV1 value being less than 1

Assess and counsel on an


appropriate inhaler technique
- Use a placebo inhaler and
spacer

© Robert Gordon University, Aberdeen


INSTRUCTIONS
- Shake inhaler before
use
- Remove the mouthpiece
cover
- Attach the inhaler to
the spacer device
- Ensure that the patient
is able to create a seal
between their mouth
and the spacer device
so the full dose is
administered and
Oral candidiasis patient can gain full
Patient has been suffering with oral benefits.
candidiasis (THRUSH) due to the inhaled Giving the Trimbow inhaler with NICE CKS - CANDIDA
corticosteroids therapy and incorrect a spacer will allow for patient to ORAL, MANAGEMENT
inhaler technique ADR take in the prescribed dose and FOR ADULTS ON
reduce the chances of IMMUNOSUPPRESSIVE
developing oral candidiasis TREATMENTS.

Fluconazole given on admission STOCKELEYS


has a severe interaction with
Citalopram- both drugs prolong
the QT interval

© Robert Gordon University, Aberdeen


Change fluconazole to a
TOPICAL MICONAZOLE GEL
2.5mL QD after meals for at
least 7 days
- first line for patients
taking oral corticosteroids

Fluconazole also interacts


severely with prednisolone which
causes hypokalemia
Monitor renal function

Counsel
- Rinse mouth with water
and when possible brush
teeth after inhaler and
spacer use in prevention of
(reoccurring) oral
candidiasis
- Maintain good oral hygiene
- Explain that patient
shouldn’t share their
spacer with anyone else
- replace the device every
12 months.

© Robert Gordon University, Aberdeen


- Raise awareness that
smoking increases risk of
oral candidiasis as it
makes mouth dry

Yearly review for patients inhaler


use, technique and symptom
control and compliance

Offer COPD education to patients


family members

Monitor FEV1, FVC, BMI, MRC


dyspnoea score

Osteoporosis Risk of osteoporosis as people requiring For GI protection prescribe PPI BNF
frequent courses of oral corticosteroids Lansoprazole 30mg OD for 4 CKS-CORTICOSTEROID
(3–4 courses per year) are more high weeks then review
risk Omeprazole as a first line has
been avoided due to the high
As an elderly patient also, requires GI interaction with Citalopram
protection
Prescribe for osteoporosis
Already risk of vitamin d deficiency as Short term calcium, vitamin D-
barely leaves the house much Accrete D3

© Robert Gordon University, Aberdeen


Long term bisphosphonates-
alendronic acid 70mg once a
week usually Wednesdays

Monitor patients kidney function,


blood glucose and pressure

Pneumonia Patient is showing signs of pneumonia Stop piperacillin 4.5g IV as its a https://
WCC, CRP, creatinine and neutrophils broad spectrum penicillin www.nhsgrampian.org
incredibly raised showing signs of antibiotic /globalassets/
infection Start co-trimoxazole 960mg foidocument/foi-
IV 12hrly public-documents1---
The green purulent sputum, high Then switch to all-documents/
temperature, and breathlessness are ORAL co-rimoxazole 960mg IMG_EmpAposter.pdf
also signs of infection 12hrly for 5 days

OR
Start on doxycycline 200mg
STAT then 100mg 12hrly upon
improvement

Second line
Clarithromycin 500mg 12 holy IV
then switch to oral upon

© Robert Gordon University, Aberdeen


improvement for 7 days

Monitor lab results for CRP, WCC,


neutrophils and creatinine

Additionally, patient requires oxygen GIVE OXYGEN


therapy Try and get oxygen therapy up
Oxygen therapy spO2 is 85% to the 90% range

Offer one of pneumonia vaccine


and a yearly flu shot
Smoking // Patient is a smoker while having During admission, smoking is an NICE CKS
cessation worsening COPD and COPD unavailable option so offer an
exacerbation. Him smoking is only NRT, pharmacotherapy and or a
making his health conditions worse nicotine replacement is advised

Smokes 15 cigarettes a day for the past PRESCRIBE


52 years Long-acting transdermal
Due to his condition he has been really patch
dependent on smoking (high anxiety) AND
and doesn’t feel ready to quit Short-acting oral spray 1-2
puffs PRN
OR
Nicotine lozenge PRN

© Robert Gordon University, Aberdeen


Advise patient on the benefit of
smoking cessation and the risks
of continuing ie. how it will
impact his COPD
Patient is also at risk of peptic
ulcers arising again due to past
history of ulcers
Increased risk of oral candidiasis
occurrence
Also reduces the efficacy of
inhaler and patient wont gain full
therapeutic relief

Relay to patients pharmacy and


community GP that he has
started smoking cessation while
admitted and recommend he
continue on it
VTE prophylaxis Risk factors for VTE prophylaxis Though there are risk factors NICE NG89
- Over 60 present, patient is already on
- Respiratory pathology Edoxaban 60mg OD so VTE is not
- Inflammatory condition required

Reduce to
Edoxoban 30mg OD until

© Robert Gordon University, Aberdeen


infection clears

Creatinine clearance is low =>


46
Increase dose back up once
creatinine clearance returns
back to 50

Adding Dalteparin 500 units will


be too much of a risk for
bleeding

AF High risk of blood clot which could lead Patient is already on bisoprolol
to a stroke, DVT or pulmonary embolism 2.5mg OD

Edoxoban (ANTI-COAGULANT) is
being reduced as well

Counsel on exactly what his


Edoxoban does

Anxiety Citalopram 40mg is quite a high dose Reduce/ taper down to NHS
for his age citalopram 20mg OD

Review if useful once COPD is

© Robert Gordon University, Aberdeen


managed better

Offer talking therapy


- anxiety might be
increased due to health
conditions and life
situations so speaking with
a professional might be
useful

Pharmacist: Date:
Pharmaceutical Issues/Category of Care Issues to consider:
 Untreated indication  Overdose  Medicine interaction  Monitoring need
 Improper medicine selection  Failure to receive medicines  Medicine use without indication  Counselling need
 Sub-therapeutic dose appropriately  Duplication of therapy  Seamless care need
 ADR

© Robert Gordon University, Aberdeen


Pharmaceutical Care Plan

Patient name: NHS number: DOB:

Priority Medical problem Care issue Proposed action Evidence

Pharmacist: Date:
Pharmaceutical Issues/Category of Care Issues to consider:
 Untreated indication  Overdose  Medicine interaction  Monitoring need
 Improper medicine selection  Failure to receive medicines  Medicine use without indication  Counselling need
 Sub-therapeutic dose appropriately  Duplication of therapy  Seamless care need
 ADR

© Robert Gordon University, Aberdeen

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