‫تقرٍر رقم (‪ / )3‬ردهت النسائَت‬

‫‪10/03/2018‬‬
‫دائرة صحت كربالء‪/‬مستشفي النسائَت والتولَد التعلَمٌ‬

‫الصَدالنَت السرٍرٍت المتدربت‪ :‬بشرى ناجح حسن البارودً‬

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 Table of contents

Subject Page no.

SOAP 3

Activities 9

Patient counseling 11

Pharmacy times 16

Patient discharge 20

Case (1) 21

Case ( 2) 22

Case (3) 23

Case ( 4) 24

Case (5) 25

Case (6) 26

Case (7) 27

Case (8) 28

Case (9) 29

Case (10) 30

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SOAP

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Case of study//
H.Kh. young female (25) years, (75) kg, chief complient are
absolute constipation, bloating, abdominal pain and burning
sensation at site of operation, fever and nausea since 4 days of
C/S operation diagnosed as severe wound infection at site of C/S
operation with pus drainage, damage and necrosis tissue.
Entered to RCU ward since 08/02/2018.
Past medical history: Past one C/S three years ago
Drugs allergy: Penicillin, ceftriaxone, cefotaxim drug allergy
and plaster allergy
Pervious medication: Amikacin vial 500mg, Metronidazole
vial 500 mg since four days.

Subjective (S):
1. Absolute constipation
2. bloating
3. abdominal pain
4. burning sensation at site of operation
5. fever
6. nausea
Objective (O):
 Blood pressure120/80 mmHg.
 Pulse rate 93 beat /min.
 Body temperature 38.5 Co
 Culture sensitivity results ( staphylococcus aureus)

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  Lab. Data in blood

Tests Results Normal values

Urea 43.28 mg/dl 15--45
Creatinine 0.63 mg/dl 0.6—1.2
WBC 18.4x103 /µL 3.70—11.00
HGB 12.7 g/dL 12.0—16.0
HCT 38.1% 38--52
RBC 4.44 x106 /µL 4.06---5.30
MCV 85.8 fL 76---96
PLT 276 x103 /µL 155---450

Assessment (A):
The development of postoperative site infection is related to the
degree of bacterial contamination during surgery, the virulence
of the infecting organism, and host defenses. Risk factors for
postoperative site infection can be classified according to
operative and environmental factors, and patient characteristics.
Bacterial contamination can occur from exogenous sources
(e.g., the operative team, instruments, airborne organisms) or
from endogenous sources (e.g., the patient’s microflora of
the skin, respiratory, genitourinary, or gastrointestinal [GI]
tract). Infection control procedures to minimize all sources of
bacterial contamination, including patient and surgical team
preparation, operative technique, and incision care, are compiled
in Centers for Disease Control and Prevention guidelines for
surgical site infection. The risk of postoperative site infection is
affected by host factors such as extremes of age, obesity,
cigarette smoking, malnutrition, and comorbid states, including
diabetes mellitus, remote infection, ischemia, colonization with
microorganisms, and immunosuppressive therapy. In addition,
the longer the preoperative hospital stay and the surgical
procedure, the greater the likelihood of developing a
postoperative wound infection, presumably as a result of
nosocomial bacterial acquisition in the former and the greater
amount of bacterial contamination occurring over time in the
latter.

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 Many experts recommend that antimicrobial prophylaxis should
be given for surgical procedures
(a) with a high rate of infection
(b) involving the implantation of prosthetic materials
(c) those in which an infection would have catastrophic
consequences.
 Classification of surgical site infections

Classification Criteria Infection

Rate (%)
Clean No acute inflammation or entry into GI, <5
respiratory, GU, or biliary tracts; no break in
aseptic technique occurs; wounds primarily closed.

Clean- Elective, controlled opening of GI, respiratory, <10

contaminated biliary, or GU tracts without significant spillage;
clean wounds with major break in sterile technique
Contaminated Penetrating trauma (<4-hr old); major technique 15–20
break or major spillage from GI tract; acute,
nonpurulent inflammation
Dirty Penetrating trauma (>4-hr old); purulence or 30–40
abscess (active infectious process);preoperative
perforation of viscera

 Optimizing surgical antimicrobial prophylaxis

Antibiotic control strategies have improved the appropriate use of
antimicrobial agents for surgical prophylaxis. The implementation of
an automatic stop-order policy for surgical prophylaxis has reduced
the duration of antimicrobial prophylaxis dramatically. These stop-
order policies can be printed directly onto an antibiotic order form.
Reviewing the process can help improve antibiotic appropriateness
and timing of administration. This was achieved in one study by
redesign of the process and education of medical staff by a
multidisciplinary quality-improvement team and it resulted in
substantial cost avoidance. In a second study, a multidisciplinary team
generated electronic quick orders allowing for a computer enhanced
decision-making process and developed an antibiotic administration
protocol. Appropriate antibiotics administered increased from 78% to

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 94%, timely administration improved from 51% to 98%, and clean
wound infection rate decreased from 2.7% to 1.4%.

In collaboration with other health care providers, the pharmacy

department of health care organizations is responsible for optimizing
the timing, choice, and duration of antimicrobial surgical prophylaxis.
Education of surgical, anesthesia, and nursing staff, supported by
hospital policy changes initiated by pharmacists improved appropriate
timing from 68% to 97% and resulted in significant cost avoidance.
More recently, a quality improvement approach developed by a
national collaborative involving multidisciplinary teams achieved a
decrease in the surgical infection rate from 2.3% to 1.7%.
Postdischarge surveillance can also help in reducing surgical site
infections.
Reference// applied therapeutic nine edition page 57-1, 57-2, 57-6

Planning (P):
 Firstly we Should give her suitable antibiotics that covers
all microorganisms such as (gram positive, gram negative
and aerobics) and not causing allergic sensitivity to the
patient so we choose meropenem vial.
 After Culture sensitivity results ( staphylococcus aureus)
We add vancomycin vial because it has good covers for
staphylococcus aureus and MRSA.
 Because of long time admision need enoxaparin 4000 unit
as prophylaxis to avoid DVD
 To maintaining fluid balance adding ringer lactate and
glucose saline.
 For GIT problems adding omperazole vial +miteclopromid
amp.
 As analgesic adding diclofenac sodium amp+ paracetamol
vial.

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RX in hospital //

 meropenem vial 1gx3 (note for nurse : diluted in 100 ml N/S and given IV
during 1/2 hour)
 Vancomycin vial 1g x2 (note for nurse : Diluted in 100 cc N/S 0.9% and
given during 60 min duration)
 Ringer lactate 500 ml 1x2
 Omperazole vial 40 1x1 (diluted in 100 cc N/S 0.9% and given during 30
min).
 plasil amp 10mg 1x3
 diclofenac sodium amp 1x1
 Enoxaparin vial 4000 Ul 1x1 (SC. injection)
 Paracetamol vial 1gx2 (antipyretic and analgesic giving during 1/4 hour)
 G/S 1x2

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Activities

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1. Daily activities:
 morning tour with doctors, to help in identifying the
patients situation, diagnosis, and what is related to their
medications.
 providing medications to patients in wards, completing
the clinical pharmacist sheet, and follow up on patient
response to medications.
 Write notes for nurses about the way to give the
treatment, method of dilution each drug and time to give
treatment.

2. Other activities:
 Active participate in the continuous medical education
program by giving three lecture to pharmacists:
 Pregnancy and antibiotics

 Participate in a training course as lecturer in

) ‫)المستحدثاث الصَدالنَت‬
for 5 day (11-16/3/2018).

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 Patient
counseling

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Case of study (1):
M.H. is 24 years pregnant woman G.P.A: 1.0.0, 80 kg, 26 weeks
triple baby present with abdominal pain and headache for 2 days
duration with no vaginal discharge, diagnosed as Pre-eclampsia
[patient with PE have symptoms (increase blood pressure more
than 130/80 and proteinuria)], past medical history: gestational
hypertension and 6 missed pregnancy, past medication history:
Aspirin 75mg and dupheston tab, vital sign [BP 190/90, HR80,
Temp. 37c]
RX:

 Hydralazine 20mg amp 1x1

 Hydralazine 25 mg tab 1x2
 Methyldopa tab 250 mg 2*4
 Duphaston 10mg tab 1x2
 Ferfolic tab 1x1
 Antacid tab 1*3
Clinical pharmacist intervention:

 Patient education on Hydralazine amp:

It should give IV by your doctor not by yours (bolus dose by
diluted amp in 5 cc N/S 0.9 % and given 1 cc every 20 min ,maintainace dose 10mg/hr by
diluted amp in 150 ml N/S 0.9%)
 Patient education on Hydralazine tab:
Take 1 tablet 2 times daily, after food, this drugs may
causes headache, nausea, vomiting and loss of appetite so
don't worry and keep regular using of antacid .
 Patient education on methyldopa tab:
Take 2 tablet 4 times daily, this drugs may make you
sleepy, so may effect performance of skilled tasks
( driving) , if this happen , don't drive or use tools or
machines. Don't stop taking this medicine unless your
doctor tells you to stop.

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  Patient education on duphaston tab:
Take 1 tablet 2 times daily, You may feel slightly sleepy or
dizzy after taking Duphaston. This is more likely in the
first few hours after taking it.
 Patient education on Ferfolic tab:
Take 1 tablet 1 times daily, Take it on an empty stomach,
at least 1 hour before or 2 hours after a meal, drink a lot of
water and fibers to avoid constipation. Avoid taking
antacids within 2 hours before or after taking it.
 Patient education on antacid tab:
Antacid should preferably not be taken at the same time as
other drug since they may impair absorption.

Reference// BNF 73

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Case of study (2):
M.H. is 28 years pregnant woman G.P.A: 2.1.0, 75 kg, 20 weeks
pregnancy, present with headache, dizziness, abdominal pain and
numbness of feet for 1 day duration with no vaginal discharge,
diagnosed as gestation diabetic mellitus (blood sugar: 320 mg\dl),
past medical history: gestational diabetic mellitus since 8 weeks
pregnancy, past medication history: S.Insulin, Pregnacare tab, vital
sign [BP 130/80, HR77, Temp. 37c]
RX:
 S.Insulin SC injection
 Lent. Insulin 15 unit
 Pregnacare tab 1x1
 Metformin tab 500mg 1x2
Clinical pharmacist intervention:
 Patient education on diabetes dietary during pregnancy
Make sure your meal plan contains:
 Complex carbohydrate, especially foods high in fiber, such
as oatmeal, brown rice, bran cereal, whole wheat bread,
whole wheat pasta, and beans.
 Fresh fruits.
 Milk.
 Fresh or frozen vegetables.
Limit these carbohydrate foods in your diet:
 Refined sugar and foods with a high content of refined
sugars (sweets)
 Refined starches, such as highly
processed breakfast cereals, instant potatoes, instant rice,
or instant noodles
 Fruit juice

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 Nurse education on S.insulin:
SC S.insulin 0.2 unit/kg= 15 IU every 2 hr until the blood
glucose reaches <250 mg/dL; then the SC insulin dose is
decreased by half (to either 0.05 or 0.1 unit/kg every 1–2
hr).
 Nurse education on Lenti.insulin:
SC Lenti.insulin 10 IU in the morning and 5 IU in the
night.
 Patient education on Pregnacare tab:
Is a dietary supplement for yours containing a combination
of minerals and vitamin, It is necessary for you during
pregnancy and take one tab after the main meal.
 Patient education on Metformin tab:
Take 1 tablet 2 times daily, with meals (to decrease GI
upset). Take it with glass of water.

Reference// BNF 73

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Pharmacy
Times

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 Boshra Baroody

karbalaa

karbalaa iraq

karbalaa, muslem 56

Has participated in the CPE-Accredited Activity

A Pharmacist's Update on the Efficacy, Safety, and Role of Long-acting

Reversible Contraception

ACPE Universal Activity Number 0290-0000-17-062-H01-P

Type of Activity: application

On February 9, 2018

This CPE activity has been designated for 0.5 contact hours (0.050 CEUs)

David Heckard

President

Pharmacy Times Continuing Education

February 9, 2018

Pharmacy Times Continuing Education is accredited by the Accreditation Council

for Pharmacy Education as a provider of continuing pharmacy education.

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 Boshra Baroody

karbalaa

karbalaa iraq

karbalaa, muslem 56

Has participated in the CPE-Accredited Activity

Long-Acting Reversible Contraception (LARC): Considerations for

Retail Health Providers and Pharmacists

ACPE Universal Activity Number 0290-0000-17-139-H01-P

Type of Activity: Application

On February 9, 2018

This CPE activity has been designated for 1.0 contact hours (0.10 CEUs)

David Heckard

President

Pharmacy Times Continuing Education

February 9, 2018

Pharmacy Times Continuing Education is accredited by the Accreditation Council

for Pharmacy Education as a provider of continuing pharmacy education.

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 Boshra Baroody

karbalaa

karbalaa iraq

karbalaa, muslem 56

Has participated in the CPE-Accredited Activity

Educating Pharmacists on the Evolving Treatment Landscape of

Diabetes: A Focus on Insulin/ GLP-1 Receptor Agonist Combinations

ACPE Universal Activity Number 0290-0000-17-101-H01-P

Type of Activity: Application

On February 10, 2018

This CPE activity has been designated for 1.0 contact hours (0.10 CEUs)

David Heckard

President

Pharmacy Times Continuing Education

February 10, 2018

Pharmacy Times Continuing Education is accredited by the Accreditation Council

for Pharmacy Education as a provider of continuing pharmacy education.

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 Patient
discharge

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