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Patient Care Process

Clinical Thinking
Jacqueline Cleary, PharmD, BCACP
Assistant Professor Pharmacy Practice
Jacqueline.cleary@acphs.edu
OB210D

Objectives
List and explain the components of the JCPP
Pharmacists Patient Care Process
Identify examples of components of the JCPP
Pharmacists Patient Care Process
Understand the role of clinical thinking in
pharmaceutical care

Pre Knowledge Check #1(Kahoot)


Which of the following pharmacists MUST employ the
patient care process:
a) CVS pharmacist counseling a patient on a new BP medication
b) Anticoagulation pharmacist calling a patient about a lab
result
c) Albany medical center pharmacist on ICU rounds
d) ALL OF THE ABOVE

Pre Knowledge Check #2 (Kahoot)


Pharmacists are ONLY responsible for the management
of a patients medications?
a) True
b) False

Patient Care
WHO
WHAT
WHERE
WHEN
WHY

Pharmacists Patient Care Process

Pharmacists Patient Care Process:


Collect
Current medication list
Prescription and nonprescription medications
Herbals and other dietary supplements

Medical history, health and wellness


information, lab results, physical exam
findings
Lifestyle habits, preferences & beliefs, health
and functional goals, and socioeconomic
factors
Patient centered factors that affect care

Pharmacists Patient Care Process:


Assess
Assess each medication for:
Appropriateness, effectiveness, safety, and patient
adherence

Assess the patients:


Health & functional status, risk factors, health data,
cultural factors, health literacy, and access to
medications and other needs

Assess immunization status


Assess for preventative care and need for other
healthcare services

Pharmacists Patient Care Process:


Plan
Develop an individualized patient-centered care plan in
collaboration with the patient and other healthcare
professionals
Must be evidence-based and cost-effective

Address medication-related problems and optimize


therapy
Set patient-specific goals of therapy
Engage patient through education, empowerment and
self-management
Include follow-up

Pharmacists Patient Care Process:


Implement
Address the identified problems including administration
of vaccines
Initiate, modify, discontinue or administer medication
therapy as authorized
Opportunity to work within a collaborative practice agreement

Provide education and self-management training to


patient
Coordinate care if needed (i.e. referral to another health
care professional)
Schedule follow-up as needed to achieve goals of therapy

Pharmacists Patient Care Process:


Follow-up
Monitor and evaluate the effectiveness
of the care plan
Continuously monitor labs and patient
feedback for:
Medication appropriateness, effectiveness,
safety and patient adherence
Clinical end points that contribute to the
patients overall health
Outcomes of care
Progress toward or achievement of therapy goals

Knowledge Check #3 (Kahoot)


Which of the following is NOT an important assessment
step when assessing a patient?
a)
b)
c)
d)

Adherence
Immunizations
Scheduled patient follow-up
Preventative Health Screenings

Knowledge Check #4 (Kahoot)


Which of the following information is important to
collect when interviewing a patient?
a)
b)
c)
d)

Medical History
Medications
Allergies
ALL OF THE ABOVE

Introduction to the
Patient Case
Get familiar with it

Patient Case
Example:
R.R. is a 55 yo M. PMH: diabetes (DM), hypertension (HTN), peripheral
neuropathy, anxiety and insomnia
SH: smoking (-), alcohol (occasionally)
FH (family history): mother- alive with diabetes; father- deceased (MI- 2008)
Allergies: penicillin's (rash)
Immunizations: UTD (up to date)
Medications: metformin 1000mg PO BID, lisinopril 20mg PO daily,
gabapentin 900mg PO TID, trazodone 100mg PO QHS, furosemide 20mg PO
daily
Labs:.

Patient Case
Example:
CC (chief complaint): patient presents today because his
provider told him to take OTC aspirin and he wants to know
which one to take

Patient Case
Treatment of a chief complaint
Disease state management
Provider question
Patient counseling
Drug-information question
Etc.
YOU HAVE TO EXTRACT INFORMATION

Patient Case Example #1


T.C. is a 33 year old male who comes to your counter
complaining of an ear ache

Collect
What questions do you want to ask T.C.?
He has not tried anything yet
He has no allergies
He has no significant past medical history
He does not take any medications regularly
He is up to date on his immunizations
He states he recently spent the weekend in Lake George and
thinks he has water trapped in his ear
No labs are available to you

Assess
What would you assess?
He has no other symptoms (ie: fever, cough)
You peer into his ear and it appears red and inflamed

Plan
You make a plan to recommend
Ibuprofen 400mg PO q6 PRN for inflammation and ear pain
AND
Carbamide paroxide 6.5% 5-10 drops BID for up to 4 days for
ear wax removal

Implement
What would you tell the patient?
What the medication is for:
How to take:
What to monitor for:

3 Prime Questions!

Follow Up
When should the patient come back?
Recommend patient see a provider if the symptoms do not
resolve in 48 hours OR
Immediately if he has an adverse reaction to therapy

Points to Remember
Gather ALL pertinent health information
Why is the patient REALLY here
Give clear recommendations and instructions
3 PRIME QUESTIONS: (1) what are you taking it for (2)
how are you taking it (3) what can you expect
Realistic and clear follow up

Patient Case Example #2


A.L. is a mother of 3 presenting to your pharmacy
counter today because she thinks her son has poison
ivy

Collect
What questions do you want to ask A.L?
Has she tried anything for him yet yet
Does her son have any allergies
Does her son have any significant past medical history
Does he take any medications regularly
Is he up to date on his immunizations
No labs are available to you

Collect
A.L. states he only takes Claritin during the spring and
fall for allergies to pollen
She also states he has no other allergies, significant
PMH and is up to date on all of his immunizations
She is concerned he got it while outside playing at a
friends house and does not want to spread the rash to
her other children

Assess
What would you assess?
Her son has no other symptoms
You can visibly see a red raised rash on both of the child's
forearms
He reports it is very itchy

Plan
You make a plan to recommend
Calamine lotion 8% apply to affected area externally as often
as is needed
Diphenhydramine 25mg PO at bedtime if needed
Wash the area with mild soap and warm water as well as
continue to keep the area clean and dry to avoid infection

Implement
What would you tell the patient?
What the medication is for:
How to take:
What to monitor for:

3 Prime Questions!

Follow Up
When should the patient come back?
Recommend to A.L. see a provider if rash continues to spread,
reaches his eyes, or any other symptoms develop
Immediately if he has an adverse reaction to therapy

Points to Remember
Non pharmacologic counseling points are often JUST AS
important as pharmacologic counseling
Clearly communicate your recommendation to the
patient (ie: verbal, written, etc.)
Collaborate with other providers if necessary

Clinical Thinking

Definition
ACCPs definition of clinical pharmacy:
Clinical pharmacy is that area of pharmacy concerned with
the science and practice of rational medication use

Comprehensive therapeutic knowledge


Experience
Problem-solving skills
Judgment

http://www.accp.com/docs/positions/whitePapers/CliniPharmCompTFfinalDraft.pdf

Clinical Pharmacist Duties


Identify patient problems
Implement and manage patient pharmacotherapy
Dispense and administer medications as needed
Educate patients
Monitor drug therapy
Consult with other patient care providers to improve
patient outcomes

http://www.accp.com/docs/positions/whitePapers/CliniPharmCompTFfinalDraft.pdf

Monitoring Therapy

Before
During
After

What Questions Would you Ask?


Mrs. B is a regular patient at College Hometown
Pharmacy
She comes to you this morning stating that she has had
a persistent cough for the past 2 weeks that will not go
away
She wants YOUR help

Take 3 minutes
In pairs: come up with 5 questions you would want to ask

Example Questions
Age
Comorbidities
PMH (past medical
history)
SH (social history)
Medications
Allergies

What has she tried?


Does anything make it
worse?
Does anything make it
better?
Quality of cough?
Dry or wet cough?
MORE.

Conclusion
Collect -> Assess -> Plan -> Implement -> Follow Up:
Monitor/Evaluate
Document ALL activities
Collaborate and communicate with other members of
the healthcare team
3 prime questions
Be comfortable with reading a patient case..

Questions?
Jacqueline Cleary, PharmD, BCACP
Assistant Professor Pharmacy Practice
Jacqueline.cleary@acphs.edu
OB210D

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