Transcription
[Music] [Music] Hi everyone, my name is Natalie Crown. Welcome to the module, A Practical Approach to Patient Assessment. By the end of this module, you will be able to: identify a patient's four drug-related needs; summarize the essential information to elicit for a medication assessment; and explain the importance of using a systematic approach to assess medication therapy.
The goal of pharmacy practice is to help patients make the best use of medication. Sometimes the concept of practice has taken on the oversimplified meaning of doing or completing tasks; providing services. In other words, practice is taken to mean whatever activities pharmacists engage in at any given time. For example, when presented with a prescription, we sometimes think they must ask about allergies, check for drug interactions, or counsel the patient. This view is simply too narrow and doesn't meet the overall drug-related needs of our patients. We need to think of our individual pharmacy practices as more than simply a list of activities, no matter how important these individual activities or services may be. As pharmacists, our responsibility is to practice pharmaceutical care, which includes meeting our standards of practice. Pharmaceutical care is defined as a practice in which the practitioner takes responsibility for a patient's drug-related needs and is held accountable for this commitment. The pharmaceutical care process involves the following three main steps in caring for your patient: assessment, care plan development (this includes developing specific recommendations to resolve the problem), and evaluation by way of follow-up.
Now let's talk about the first step, assessment, in more detail. The purpose of our assessment is threefold: to understand the patient and the patient's medication experience; to determine if the patient's drug therapy is appropriate, effective, safe, and if the patient is able to adhere with his or her medications; and finally, to identify drug therapy problems. A patient assessment is a necessary component of each patient interaction, be it for a new prescription or for a refill. It involves three primary activities that we need to complete: interaction with the patient to gain new information or to confirm information in their pharmacy records; asking questions about the patient's medication experience, including the patient's beliefs, perceptions, attitudes, behaviors, and understanding about drug therapy; and making clinical decisions about the patient's medication to identify actual or potential drug therapy problems.
Let's begin with identifying the information we need as part of our initial assessment for a new prescription to make clinical decisions with our patients. This includes: patient data (for example, demographic information, their medication experience); secondly, disease data (current medical conditions, relevant past medical history); and finally, drug data (allergies, current medications, past medication use, social drug use, or immunizations). This initial information is usually gathered through dialogue with the patient or their family or caregivers. It should be documented in the patient record in the pharmacy computer system for future use. On each subsequent fill of a medication, this information should be reviewed as part of your routine clinical assessment. This table summarizes some of the important information you may need to collect to complete initial medication assignment. After you have collected the relevant information, the process used to identify whether or not the patient is experiencing a drug therapy problem requires an assessment of four drug-related needs: indication, effectiveness, safety, and adherence. In essence, the process requires the continuous assessment of four logical questions: 1. Does the patient have a clinical indication (for example, medical conditions) for each of his or her drug therapies, and is each of the patient's indications being treated with drug therapy? 2. Are the drug therapies effective for the patient's medical condition? 3. Are the drug therapies as safe as possible? 4. Is the patient willing and able to take the medication as intended? This table highlights the seven drug therapy problems patients may encounter.
[Music] [Music] Let's look at a scenario to see this initial assessment in practice. In this scenario, the mother, Jeanine, brings in a prescription for her five-year-old daughter, Jean. The prescription is from the walk-in clinic next door, and it's for cefalexin 250 milligrams four times daily for seven days. Before viewing the scenario, take a moment to ask yourself what information will you gather from the mother to assess this prescription for Jean.
Hi, how can I help you today?
Hi, I just got this prescription from the walk-in clinic for my daughter, Jane.
Okay, so what happened? Why did you come to the walk-in?
Jane was outside playing in the yard yesterday after dinner with her friend, and the neighbor's cat came over the fence. I think they must have gone too close to the cat, and she got angry and bit her finger. It all happened so fast. I tried to clean the finger after it happened and used an antibiotic ointment, but this morning her finger was so red and swollen, and you could see the puncture marks where the cat's teeth went in. So I took her over to the doctor.
I see. That sounds like it would be upsetting for everyone. You did the right thing by taking her to the doctor, and an antibiotic is the right choice here. It should bring the redness and swelling down in about a day or so. So before I get this ready for you, I want to ask you just a couple of questions to make sure that it's the most appropriate for Jane and so that we can get her finger feeling back to normal as quickly as possible. Okay?
Does Jane have any medical conditions?
No, she's a healthy little girl.
Okay, that's great. Is Jane taking any other medications, any pills, puffers, or anything over-the-counter, including vitamins?
No, nothing at all.
Okay. Now, does Jane have any allergies to medications, or has she had a bad reaction to a medication in the past?
No, we're really lucky. She's only been on antibiotics one time before, and there's been no problems with it.
Okay, perfect. So now, in children, often the dose of the antibiotic is based on their weight. Would you know approximately how much Jane weighs so that we can double-check the dose of the medication?
She weighs about 40 pounds.
Okay, perfect. That's great. So just one final question for you: I want to make sure that this is as easy and convenient for Jane to take as possible. Some children prefer pills over liquid, and some prefer liquid over pills. Any difficulty swallowing? Do you know what would work best for Jane?
She would prefer liquid. I think that would be easiest for Jane.
No problem. So take about 15 or 20 minutes, feel free to have a seat in our waiting area, and I'll let you know when it's ready for you.
That's great, thanks.
Now I know cefalexin is the drug of choice for many types of skin infections like cellulitis, but I haven't come across a cat bite before. I better just check quickly to see what types of bacteria we need to cover in this situation. Hmm, it says here the antibiotic of choice is actually amoxicillin, and that cefalexin will not provide adequate coverage for all of the most likely organisms involved in a cat bite, and that the infection should be treated for ten days. I'm going to call the physician, but first let me just calculate the correct dose so I can make a recommendation to the doctor.
In that example, the pharmacist was able to collect the relevant information required to assess the four drug-related needs (indication, effectiveness, safety, and adherence) and use that information to come up with a recommended intervention to solve the problem. In this case, the resolution was the pharmacist called the physician with a suggested recommendation including drug, dose, and duration. You can see how omitting a component of the assessment may have resulted in missing key information required to identify the correct drug therapy problem. For instance, asking about the child's weight, allergies, and current medications but not about the purpose of the medication may have resulted in the crucial piece of information—the cat bite—being overlooked.
Now let's take a look at what an assessment for a refill prescription may look like.
I'm interjecting, how can I help you today?
I just need a refill of my blood pressure medication, the ramipril.
Okay, let me pull up your profile here. Alright, so I see that you're on the ramipril 10 milligrams. How is your blood pressure these days? Are you able to check it occasionally?
Yep, I check it each time I come to the pharmacy, and my doctor checks it at all my appointments. Usually around 130 over 80, which Dr. Jones seems happy with.
That's great. Sounds like it's working well for you. Are you having any side effects or any concerns with the medication, or any trouble remembering to take it?
Nope, no complaints really, and I haven't noticed any side effects. I take it every morning with my breakfast, so no troubles remembering for now.
Okay, great. So give me a few minutes and I'll get that ready for you.
As you can see in this example, Mr. Jackson was getting a chronic medication refilled; he has been on the medication for months with no changes. However, the pharmacist still worked through a brief assessment, ensuring Mr. Jackson's ramipril was still indicated, effective, safe (since he wasn't experiencing side effects), and that he was able to adhere to it.
The same refill example could have gone another way. Let's see it play out.
[Music] I'm interjecting, how can I help you today?
I just need a refill of my blood pressure medication, the ramipril.
Okay, let me pull up your profile here. Alright, so I see that you're on the ramipril 10 milligrams. How is your blood pressure these days? Are you able to check it occasionally?
Yep, I check it each time I come to the pharmacy, and my doctor checks it at all my appointments. Usually around 160 over 90. Here, I write them down so I could show you my blood pressure numbers.
Okay. Sounds like the ramipril is not bringing your blood pressure down as much as we would like to see (usually less than 140 over 90). Are you having any side effects or any concerns with the ramipril, or any difficulty remembering to take it?
No, no complaints really, and I haven't noticed any side effects. I take it every morning with my breakfast, so no troubles remembering for now.
Okay, well that's good to know. I am still a little bit concerned over your blood pressure, as you know we like to keep the blood pressure under control to reduce your risk of stroke and of heart disease. Now, over time, sometimes people do need to increase the dose of the ramipril or add on an additional medication to work alongside it. Now you're already taking the recommended dose of ramipril, which is 10 milligrams, so it might be time for your doctor to consider adding on an additional medication. It is common for people to need two, and sometimes even three, medications to help control their blood pressure. So what I'm going to do is I'll send a note to your doctor and let them know about our discussion today, and then we can go over a couple of things that you can do in addition to the medication to help control your blood pressure. How does that sound?
Sounds great.
Okay, give me a few minutes and I'll be right back with you.
In this example, the pharmacist goes through the routine patient assessment with the refill request: Is the medication indicated, effective, safe, and can the patient adhere? In doing this, he notes the patient has high blood pressure even though he is taking ramipril and has identified a drug therapy problem. If the pharmacist had just refilled the medication based on a review of the patient profile, they would have missed this key information. Conducting a brief assessment with each new and refill prescription is very important to ensure we are optimizing medication therapy for our patients.
There are many strategies for gathering information and many interview techniques that one could use. Since our goal is to identify the information required to assess the four drug-related needs, I would like to close by introducing a tool that may be helpful for practice. Here is a series of personalized, open-ended questions that can be employed to gather information on both new and refill medications. If a patient has difficulty answering some of these questions, this may suggest that perhaps adherence could be an issue to further explore. Once you've gathered the responses, we can then go back and apply the four questions we discussed previously: 1. Does the patient have a clinical indication for each of his or her drug therapies, and is each of the patient's indications being treated with drug therapy? 2. Are the drug therapies effective for the patient's medical conditions? 3. Are the drug therapies as safe as possible (no contraindications and minimal side effects)? 4. Is the patient willing and able to take the medication as intended? Your response to these questions will help you identify the drug therapy problem, which can then be translated into a clear recommendation or intervention that you will follow up at a subsequent visit.
In summary, we have reviewed the problem-solving process that is central to our role in pharmacy practice: to assess medication therapy. This process provides the basis to identify and resolve drug therapy problems for our patients. Using a defined process helps us to ensure positive drug therapy outcomes for the patients we serve. I wish you the best of luck in your practice.
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