CHAPTER # 07 PHARMACEUTICAL CARE

PHARMACEUTICAL CARE

INTRODUCTION:

DEFINITION:

Pharmaceutical care is that component of pharmacy practice which entails the direct interaction
of pharmacist with the patient for the purpose of caring for that patient’s drug related needs.

Or

Pharmaceutical care is a patient-centered practice in which the practitioner assumes

responsibility for a patient’s drug-related needs and is held accountable for this commitment.

Or

"The responsible provision of drug therapy for the purpose of achieving definite outcomes that
improve a patient's quality of life."

EXPLANATION:

Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving
the elimination or reduction of a patient's symptomatology; arresting or slowing of a disease
process; or preventing a disease or symptomatology.It describes specific services activities
through which an individual pharmacist cooperates with patients and other health care
professionals in designing, implementing & monitoring a therapeutic plan that will produce
specific outcomes for the patient. Goal of pharmaceutical care is to optimize the patient’s health-
related quality of life and achieve positive clinical outcomes, within realistic economic
expenditures.

This process requires a clinical pharmacist to review a patient's medication with reference to the
doctor's diagnoses, laboratory tests and patient's information. The clinical pharmacist must
therefore work very closely with the doctor and patient in order to gain a correct understanding
of the relevance and impact of the various medications on the patient's pathology.

The pharmaceutical care process was originally conceived to be undertaken in a community

pharmacy by community pharmacists. This concept was introduced by helper and strand (1990)
when they published an article in ASHP. In 1996 the Pharmaceutical Society of NZ began a
programme to implement the process throughout New Zealand. While some 500 pharmacists
undertook an expensive training, it was found that the basic skill level of most pharmacists was
not sufficient to enable them to undertake an in-depth review of the patients' medication.
Pharmacists are now required to complete a postgraduate diploma in clinical pharmacy to enable
them to practice as a Clinical Pharmacist before being considered competent to work at this
level.

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SCOPE OF PHARMACEUTICAL CARE:

i. Pharmaceutical care can be provided in different health care setting such as hospitals,
clinics, nursing home etc.
ii. Pharmaceutical care can be provided at different stages of patient journey through a
clinical setting or health care setting for seeking a medical care.
iii. There are some distinguishing features which make it different from traditional pharmacy
care and clinical pharmacy practice. Provision of pharmaceutical care may overlap with
them but it’s not the same. Some of the features are as follows;
a. The primary focus in pharmaceutical care is patient.
b. Continuity in the processes and activity.
c. Responsibility of delegation of powers related to medication.
d. The ultimate goal is to improve the patient quality of life by interventions.
iv. Pharmaceutical care is providing by performing the following activities, e.g.
a. Taking medication history.
b. Identifying different drug related problems.
c. Designing a proper pharmaceutical plan.
d. Evaluation and monitoring of the outcomes which be positive or negative.

PHARMACEUTICAL CARE PLAN:

DEFINITION:

A plan developed by clinical pharmacist for individual patients which is evaluated and revised
according to the changing needs of the patient on continuous basis for the purpose to formulized,
optimize and document a specific cores of treatment.

Or

The individualized comprehensive medication therapy plan develops for an individual patient
based on clearly defined therapeutic goals and that revised on continuous basis.

EXPLANATION:

The pharmaceutical care plan is a written, individualized, comprehensive medication therapy

plan based on clearly defined therapeutic goals. The pharmaceutical care plan, which is available
to all pharmacists caring for a patient, is updated with each major change in patient status. It is
important that the physician be informed about the care plan to ensure common goals. Patients
should also be informed about the general content of the care plan as means of gaining their
agreement regarding drug therapy.

Patient care planning involves systematically assessing a patient's health problems and needs,
setting objectives, performing interventions, and evaluating results. Not all patients require a
written PCP. Pharmacists must assess their own patients and identify specific areas on which to
focus. For example, the pharmacist may want to identify patients with specific diseases (e.g.,
asthma, hypertension, diabetes mellitus, or hypercholesterolemia).

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CHAPTER # 07 PHARMACEUTICAL CARE

Pharmaceutical care planning is a systematic, comprehensive process with three primary

functions:

1. Identify a patient's actual and potential drug-related problems.

2. Resolve the patient's actual drug-related problems.
3. Prevent the patient's potential drug-related problems.

STEPS FOR DEVELOPING AND MANAGEMENT OF PHARMACEUTICAL CARE

PLAN:

The development of a PCP can be summarized as a eight step process involving the SOAP
format (Subjective data, Objective data, Assessment, and Plan of care). The process can be
described as follows.

Step 1. Gathering Information (patient data):

Collection of data may also called as development of patient data base. First start with patient
demographic data (age, race, sex etc) which is collected. The pharmacist should gather an
accurate medication history, including both prescription and nonprescription medications and the
reasons the medications were prescribed or taken. The pharmacist will likely have to obtain some
information from the physician, such as laboratory test results and hospitalizations. If so, the
pharmacist should get written permission from the patient before soliciting this information.
Once this information is compiled, the preparation of a PCP can begin.

Step 2. Identifying Problems:

A drug related problem is an event of circumstances, which involving in drug therapy that
actually or potentially interferes with the desired health outcome. It can also be defined as any
underisrable events, experienced by a patient which involves or suspect to involves drug therapy
and that interfares with achieving the desired goals of therapy. Different catogries of drug related
problems are given below, these are;
a. Untreated condition(s)
b. Drug(s) without medication(s).
c. Improper drug (drug product) selection.
d. Subtherapeutic dosage.
e. Excessive dosage: In this condition dose should be adjusted.
f. Adverse drug reactions
g. Non-compliance
h. Drug interactions.

Step 3. Setting of outcomes goals:

Outcome goals must be established for each drug-related problem so that the pharmaceutical care
planning process can be effective. Outcome goals should be definite, realistic and, if possible,
measurable. Most outcome goals relate are:

1. Approach to normal physiology (i.e., normalize blood pressure).

2. Slow down progression of disease (i.e., slow progression of cancer).
3. Alleviate symptoms (i.e., optimize pain control).

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CHAPTER # 07 PHARMACEUTICAL CARE

4. Prevent adverse effects.

5. Control medication costs.
6. Educate the patient about his or her medication.
7. Normalization of labortary data.

Step 4. Designing a pharmacotherapeutic regimen:

Pharmacotherapeutic regimens should be selected on the basis of;
 Effecetiveness
 Safety
 Economic/cost effectiveness
 Availability
 Patient convenience
 Individualized
 Patient education and counselling.
Designing a pharmacotherapeutic regimen is done by the following way.
1. Therapeutic regimens:
a. Existing therapy: For example, a pharmacist is asked to wiork with a patient for
whom one or more agents are already prescribed for the disease process or
problem. Evaluate and revise the current regimen if appropriate.
b. Initial therapy: A pharmacist is asked to work with a patient whose condition
was newly diagnosed or is asked to develop an initial treatment plan. Then the
pharmacist should list the therapeutic options (drug and regimen) most likely to
achieve the desired end points. Then select the best suited therapeutic option for
the patient well being.
2. Goal setting and behavior regimens: The patient is an essential partner for setting and
achieving intermediate and short term goals and the behaviour changes necessary to
achieve those goals. To construct effective behaviour regimens, the pharmacist
practitioner must incorporate the following concepts;
a. Identify the type of goal being set, such as the following;
 Start a new positive action, e.g. start an execise program.
 Increase the frequency or intensity of a positive action e.g. overdose
 Stope or decrease the frequency or intensity of a destructive action. e.g.
Stope smoking.
 Continue the action that is perfect. e.g. continue to exercise 30 min a day.
b. State the behaviour goal in terms that are clear, specific and reasonable.
 Set time limits. e.g. over the next 3 weeks.
 Target a specific action. e.g. i will walk.
 Set a measure and frequency. e.g. six blocks, three days a week.
 Divide a big task into several small ones, making each change small
relative to the current patient behavior.

Step 5. Designing a monitoring Plan:

Pharmacist will design a proper monitoring plan, to evaluate the progress towards the
pharmacotherapeutic objectives. It may be in the form of some labortary values or some sign and

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symptoms monitoring and frequency of monitoring will also be define in the plan. e.g. LFTs,
INR value, B.P, improved in the pain relief will be monitor after every 12 hour etc.

Step 6. Implementation of pharmacotherapeutic regimen with corrosponding monitoring

plan:
In order to implement the pharmacotherapeutic and monitoring plan, the pharmacist will order
the medication therapy according to the regimen prescribed and lab test, the signs and symptoms
of the patient will be check from time to time and the patient will be counsel about the
medication or some side effects which may occure with the prescribed medications.

Step 7. Monitoring the Outcomes:

Outcomes that will be used to evaluate the success of the PCP treatment plan must be
meaningful, measurable, and manageable. Outcomes are specific, measurable indicators for the
goals of treatment. Thus, they should be identified in the planning process.
The possible outcomes may either be positive or negative or neutral. In case of the negative or
neutral outcomes, the pharmaceutical care plan should be review and if possible the plan should
be re-design by some possible interventions according to the need of the individual patient.

Step 8. Documentation:
Documentation help to improve the quality of care. It is used for the purpose of justification of
services. It is also used for legal as well as research purpose.
Documentation should include these components, these are;
1. Patient data such as name, medical record number, location, date of hospital admission (if
applicable). age, sex, height, weight, known medication or other allergies, and medication
history.
2. Name of pharmacist(s) responsible for developing and implementing the PCP.
3. Patient problem(s) listed Individually in order of potential pharmacotherapeutic impact
(highest to lowest priority). Subjective and objective data that lead to identification of a specific
problem and potential drug-related problems should also be included.
4. Date on which a patient problem is identified. Many diseases remain chronic throughout the
patient's life. Problems such as urinary tract infection or upper respiratory tract infection usually
resolve in 10 to 14 days.
Methods of documentations:
Different methods are used to describe and document the interventions intended or provided by
the pharmacist. Some healthcare facilities may specify one format over the other format.
Pharmacist need to become proficient in each.

a) Format of a FARM note:

The description & documentation of interventions intended or provided by pharmacist. FARM

stands for;

 F = Findings: The patient specific information that Gives the basis for recognition of
pharmacotherapy problems or indication for pharmacist intervention. Within the FARM
format, findings include subjective and objective information about the patient.
 A = assessment: The pharmacist’s evaluation of the findings, including statements of,

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i. Any additional information needed to best assess the problem to make

recommendation.
ii. The severity, priority or urgency of the problem.
iii. The short term & long term goals of the intervention proposed.
Short term goals:
Examples are;
a. Elimination of symptoms
b. Lowering of BP
c. Management of acute asthma without requiring hospitalization
Long term goals:
Examples are;
a. Prevent recurrence of disease.
b. Control B.P.
c. Prevent progression of diabetes
 R = resolution: The plan includes actual or proposed actions by the pharmacist or
recommendations to other healthcare professionals. The retionale for choosing a specific
intervention should be stated.
It including prevention, observing & reassessing, counseling or educating the patients &
care givers, informing the prescriber, making recommendation to prescriber and
withholding medication or advising against use.
 M = monitoring: The parameters and timing of follow upmonitoring, to assess the
efficacy, safety & outcome of the intervention. This portion of FARM note should
include the following;
i. The parameter to be followed. e.g. pain, depressed mood, serum potassium level.
ii. The intent of monitoring. e.g. efficacy, toxicity, adverse event.
iii. How the parameter will be monitored. e.g. patient interview, serum drug level,
physical examination.
iv. Frequency of monitoring . e.g. weekly, monthly.
v. Duration of monitoring. e.g. until resolved, while on antibiotic.
vi. Anticipated or desired finding. e.g. no pain, euglycemia, healing of lesion.
vii. Decision point to alter therapy when or if outcome is not achieved. E.g. pain still
present after 3 days.

b) Format of a SOAP note:

The SOAP format is the one used most often by medical practitioners; however, when used
within the pharmaceutical care context, the content of the sections must be revised to match the
pharmacist’s legal scope of practice.

 S = Subjective: The patient specific subjective information that gives a basis for, or leads
to, the recognition of a pharmacotherapy problem or indication for pharmacist
intervention. Within the SOAP format, patient findings are delineated into subjective and
objective data.

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i. Subjective data are open to individual interpretation. Examples of subjective

findings include the patient’s statement of complaint ( the chief complaint; C.C)
and duration or severity of symptoms.
ii. Sometimes, the data to be noted are not clearly delineated as subjective or
objective or there may be prepoderance of one type of data. In these instances, the
subjective and objective data may be combined as a single section, labeled S/O
findings.
 O = Objective: The patient specific objective information that gives a basis for or leads
to the recognition ofa pharmacotherapy problem or indication for pharmacist
intervention. Objective data are easily duplicated or quantified. e.g. laboratory data,
weight, height, blood pressure and pulse.
 A = Assessment: In the medical model, the assesment states the physician’s working
diagnosis and/or possible explanations for the patient’s medical problems. It is a brief,
complete description of a problem. In the pharmaceutical care model, however, diagnosis
is not normally within the pharmacist’s scope of practice. Instead the assessment section
includes the pharmacist’s evaluation of the subjective and objective findings in a manner
similar to the description of the assessment in the FARM format.
 P = Plan: It is a detailed description of further workup, treatment, education, monitoring
and follow-up relative to assessment. In the medical model, the plan states the
physician’s intended drug regimens, surgical procedures and/or diagnostic tests. In the
pharmaceutical care model, pharmacists may not have the authority tointiate or alter drug
therapy regimens or order laboratory tests. Laboratory or prescriptive authority may be
granted on a state by state basis, under collaborative protocol with specific physician(s)
or within a specific healthcare facility or system. Actions included within the plan
section should be identified as tecommended actions when appropriate. In the
pharmaceutical care model, the plan is usually expanded to describe information included
in the monitoring and follow-up section of the FARM note.

PHARMACEUTICAL CARE PLAN SUMMARY:

In summary, the general steps involved in creating a pharmaceutical care plan are:

1. Create comprehensive patient database.

2. Assess for actual and potential drug-related problems.
3. Establish therapeutic goals.
4. Specify monitoring parameters with end points and frequency.
5. Document the patient's progress towards therapeutic goals.

The care plan function in Kinetics is basically just a skeleton that you can expand on because
plans will differ depending on the practice setting in which the program is being used. Acute
care, homecare and long term care all have different monitoring parameters and schedules. The
default care plan for a drug can be changed on the Edit drug model function which is accessed
via the drop down menu tree or by the keyboard shortcut Ctl+E. The care plan field is free form
text entry, you can enter anything you like in this field.

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AN EASY APPROACH TO CLINICAL PHARMACY