Module 03: Therapeutic Care Planning

Current Content Expert: Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Legacy Content Experts H.E. Davidson, PharmD, MPH Partner, and Assistant Professor of Internal Medicine Insight Therapeutics, and Eastern Virginia Medical School, Norfolk, VA Barry Rumble, RPh Director of Consulting Services Riverside Regional Convalescent Center

Course Objectives: At the conclusion of this application based activity, the participant will be able to: Assess the basic elements of therapeutic care planning. Specify the steps and principles in designing a therapeutic regimen, explaining the purpose and contents of the medication regimen and the anticipated outcomes of the data assessment process.

03.01.01 Steps in Therapeutic Care Planning Define Needs:

Determining health care problems Defining health care needs Identifying patient needs

Identify Goals:

Therapeutic goals Pharmacological goals Goals of other practitioners

Design the Therapeutic Regimen Monitor the Patient Document Patient Progress Therapeutic care planning involves defining a patients health care needs based on actual and potential health care problems. By accurately identifying these problems, relevant health care needs arise. It is from these needs that pharmacological and other therapeutic goals are established, and a therapeutic regimen is designed, implemented, and monitored. Therapeutic care planning focuses on the whole patient in order to: A. Identify as many opportunities for pharmacological intervention as possible B. Ensure patient compliance with the therapeutic regimen C. Treat possible psychological barriers to success of the therapeutic care plan D. All of the above

CORRECT ANSWER: B. Therapeutic care planning takes into account physical, psychological, and any other barriers thay may prevent the patient from maintaining compliance with the recommended therapeutic regimen.

03.01.02 Identifying Actual and Potential Health Problems

Patient demographics Medical, social and family history Medications and related products Patient complaints, signs, and symptoms

In order to identify a pharmacotherapeutic need, you must look to the underlying problem and collect data to gain the most complete picture possible. These data must provide clues to actual or potential health care problems. Data on patient characteristics, medication history, other substances being used, presenting complaints, and signs and symptoms should be gathered during this part of the care planning process. 03.01.03 Identifying Problems: Patient Demographics, Social and Medical History

Demographic Data
o o o o o

age gender ethnicity race religious preferences

Family History Social History Medical History

o o o

past health problems past surgeries, treatments, etc. current health status physical, nutritional, cognitive

Data on patient demographics, such as age, gender, ethnicity, race, and religious preferences should be collected. The patients family, social and medical histories are also relevant. Current health status considers the patients nutritional, functional, and cognitive status, as well as other patient-specific issues.

03.01.04 Identifying Problems: Medications and Related Products

Present and past

o o o

how and when drugs are/were taken allergies and drug reactions toxicity profile of drug

Appropriate dose Identify drug interactions and duplication

o o o

drug-drug interactions drug-food interactions duplicative medications

Drug administration technique (e.g., PO, IV, PEG) Other products consumed (e.g., smoking, alcohol, caffeine) Patients beliefs in therapy Compliance
o o

Medication administration record (MAR) Refill records

Information on concurrent medications is critical in order to identify actual or potential health care problems. Both past and present medication histories should be considered in regards to how and when the drugs were taken, allergies noted, and the toxicity profile of the drug. Drug-drug interactions, drug-food interactions, and duplicative medicines should be identified and screened. The technique for administering the drug should be noted and compliance assessed through reviews of the medication administration record and refill records. Information on other products consumed such as caffeine, alcohol, smoking and homeopathic remedies should also be gathered at this time.

03.01.05 Identifying Problems: Patients Complaints, Signs, and Symptoms

Present medical problems

o o o

description severity duration

Impairments

Disabilities Perception of disease process

The patients complaints, signs, and symptoms should be described and assessed for severity and duration. Impairments and disabilities should be noted along with the patients perception of the disease. Remember that subjective and objective both may influence the identified need and potential solution.

03.01.06 Identifying Problems: Data Collection Sources Individuals:

patient physician physician extenders (nurse practitioners / physician assistants) other caregivers (e.g., nurses aids, nurses, other ancillary staff) family

Records:

medical records patients pharmacy profile lab reports

Medical Professionals:

physicians nurses others

In order to confirm the medical problem, the pharmacist should collect patient data from a variety of sources including the patient, physician, other caregivers or family members. Medical records, pharmacy profiles, and laboratory reports can help uncover quantifiable data. Observations of medical professionals such as

physicians, nurses and other long-term care facility staff can reinforce qualitative data findings.

03.01.07 Considerations in Defining Health Care Needs

Ability to resolve actual problems Ability to avoid potential future problems

After collecting the various data and identifying the problem or problems, the health care needs should become evident. Two considerations must be kept in mind when identifying needs: the ability to resolve current problems and the ability to avoid potential future problems.

03.01.08 Defining Needs: Care Planning Process and Patient Factors

Focus must be on whole person Individual needs must be taken into account Patients must have:
o o o o

an understanding of their illness an understanding of their drug therapy realistic expectations their concerns addressed

The care process is driven by patient needs and preferences; therefore, the care plan must take the whole person approach, rather than focus solely on the pharmacotherapy that addresses an illness. The patients individual needs must be considered at the onset of care planning, because cooperation and compliance are essential to the success of the plan. Compliance depends on patients having a basic understanding of their illness and how their actions can affect the condition. Patients also need to have an understanding of their drug therapy, so that they can help monitor their progress, and report any unexpected effects that may arise. Working with the patient to set realistic therapeutic expectations is important, as is addressing any concerns they may have about the condition and treatment. Side effects, allergies, and costs are common concerns of the elderly undergoing treatment.

03.01.09 Special Consideration for Long Term Care Patients

For the elderly in long-term care facilities, many of these issues will not apply. Due to the high prevalence of cognitive and functional impairment in this population, many of these issues will be addressed through caregiver discussions or directed by regulatory guidelines. Frequently, the resident will be unable to express clinical outcome of drug therapy. 03.01.10 Characteristics of Therapeutic Goals

measurable observable specific attainable over a definite time period addresses the gap between where patient is and where patient should be

The ultimate goal of care is to improve a patients quality of life through reaching defined or predefined medication-related outcomes that address a need. Therapeutic goals must be measurable and observable. The more specific the goal, the greater ability to measure the goal. All goals should have definitive and realistic time frames in which to attain them. Understanding where patients are in terms of their health status and where you would like them to be is the first step in determining goals for a given condition.

03.01.11 Establishing Therapeutic Goals: Roles of the Patient and Family

The patient can help establish quality of life goals Patient involvement must be monitored The patients family may play a key role in setting goals and achieving therapeutic outcomes To be effective, care must be provided directly to the patient, and require his or her participation. Patients who are involved in establishing quality of life goals for their therapy are more likely to reach them. However, this involvement must be monitored to ensure that the patient does not interfere with the reaching the desired therapeutic outcomes. For

example, the patients administration of medication must be periodically checked to make sure that he or she is taking the correct dosages. Elderly patients who are cognitively or functionally impaired may not be able to become directly involved in their own care. Family intervention is a major consideration in setting goals and meeting therapeutic outcomes for these patients.

03.01.12 Establishing Therapeutic Goals: Roles of the Pharmacist and Other Caregivers

The pharmacist and other medical professionals must provide education as to how to best achieve therapeutic goals The roles of the patient, family, pharmacist, and other caregivers must be considered when planning and providing patient care

While patients have a responsibility to help achieve desired outcomes, the pharmacist and other medical professionals are responsible for educating caregivers and patients about behaviors that will help patients reach their therapeutic goals. The roles and responsibilities of the patient, family, pharmacist and other caregivers must all be considered when defining goals and providing care.

03.01.13 Establishing Therapeutic Goals: Medication-Related Considerations

Whether or not to use medications, based on

o o o o

advance directives potential to achieve desired outcomes potential risks patient or family preferences

Which medication to use How to deliver medication selected

o o o

dosage amounts and frequency routes of administration duration of therapy

Medication safety issues Monitoring protocols

Education and counseling needs

The decision to avoid pharmacotherapy is a valid care option for some patients based on advance directives, the ability to achieve desired therapeutic outcomes, potential risks, and patient or family preferences. If pharmacotherapy is used, the pharmacist must consider other medication-related factors that affect therapeutic goals. These factors include the nature of the medication selected, the dosage, routes of administration, the drugs safety profile, monitoring and counseling considerations, and quality of life issues.

03.01.14 Determining and Prioritizing Pharmaceutical Goals Determine Goals by Integrating:

problem characteristics health care needs patient/family needs and preferences therapeutic goals

Prioritize Goals by Considering:

what problems will be addressed what problems will be the responsibility of the pharmacist what goals will be addressed first

Achieve Goals by Making Sure Each Goal:

is measurable is attainable is associated with a specific time frame

In order to determine pharmaceutical goals, the pharmacist must integrate the problem characteristics, the health care needs and preferences of the patient and family, and the therapeutic goals established by health professionals and caregivers involved in the case. These pharmaceutical goals are then prioritized by clearly identifying what problems will be addressed, what problems will be the responsibility of the pharmacist, and what goals will be addressed first. As with all therapeutic goals, each pharmaceutical goal should be measurable and associated with a specific time frame for achievement.

03.01.15 Pharmaceutical Goals and Therapeutic Outcomes

Focus on meeting the patients health care needs, not just resolving drug therapy problems Consider therapeutic goals of other health care providers and their impact on pharmacotherapy Remember that therapeutic goals change as the patients health status and needs change

When identifying pharmaceutical goals, one should keep in mind that such goals are definite or predefined, and related to therapeutic outcomes. Pharmacists must focus on meeting the patients health care needs, not simply resolving drug therapy problems. The therapeutic goals of other health professionals on the team must be considered, as well as the impact of these goals on pharmacotherapy. Remember that therapeutic goals and the medication regimen will require updates as the patients status changes.

03.01.16 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Cipolle, R.J., Strand, L.M. & Morley P.C. (1998). Pharmaceutical Care Practice. New York: McGraw Hill. updated 2nd edition available ( 2004). Faden, R. & German, P. S. (1994). Quality of life. considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy.

Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 12821290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/

Module 3, Section 2: Designing a Therapeutic Regimen

Current Content Expert: Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Farmington, CT Legacy Content Experts H.E. Davidson, PharmD, MPH Partner, and Assistant Professor of Internal Medicine Insight Therapeutics, and Eastern Virginia Medical School, Norfolk, VA Barry Rumble, RPh Director of Consulting Services Riverside Regional Convalescent Center Newport News, VA

03.02.01 Steps in Designing a Therapeutic Regimen Define Needs Identify Goals Design the Therapeutic Regimen:

Select the proper regimen

o o o o

drug selection simplify regimen dosing written directions and product information

Explain the treatment regimen Consider factors that affect compliance

Devise strategies for avoiding adverse drug reactions

Monitor the Patient Document Patient Progress

After determining the medical problem, health care needs and therapeutic and pharmacologic goals, a therapeutic regimen may be designed. Designing a therapeutic regimen involves selecting the appropriate interventions, explaining the regimen to the patient and family and considering factors that influence noncompliance. Strategies for avoiding adverse drug reactions are also considered at this time. 03.02.02 Principles for Designing a Therapeutic Regimen

Individualize therapy based on the patients:

o o o o

overall health concomitant disease concurrent medications drug therapy problems Is the problem caused by medication? Should the problem be treated by medication?

Consider the role of medications:

o o

Consider medical risks and potential toxicity Identify and evaluate therapeutic alternatives

The therapeutic regimen must be individualized to the needs of the patient. The pharmacist must consider individual patient characteristics such as overall health, concomitant disease, and concurrent drug therapy problems. Each health care problem needs to be considered with regard to whether the problem is caused by a medication or needs to be treated with one. Medical risks and potential medication toxicity must also be considered. Therapeutic alternatives should be identified and evaluated for potential inclusion in the pharmaceutical care plan.

03.02.03 Factors in Selecting the Proper Medication

Efficacy and effectiveness Safety Contraindications Real and potential drug-related problems
o o

drug-drug interactions drug-food interactions

Patient characteristics Route of administration Regulations regarding use

o o o

Formulary of approved medications Approved uses of the selected medication Legislative guidelines (e.g., OBRA, other CMS regulations)

In selecting a proper medication and regimen, the pharmacist must consider the drugs efficacy, safety, contraindications, real and potential drug interactions, and any patient characteristics that might affect treatment. In most instances, the selection of an appropriate medication must take into consideration the formulary of approved medications within the health care system, approved uses of the selected medication for specific patient conditions, and regulations such as the Omnibus Budget Reconciliation Act and guidelines from CMS regarding medication use in nursing facilities.

03.02.04 Determining Proper Administration of the Medication Frequency of Administration:

half-life and duration of action immediate versus sustained release

Type of Administration:

oral nasogastric/gastrostomy

topical injectable

Dosing:

pharmacokinetic issues (e.g., renal and hepatic function) concomitant medications patient factors (e.g., age, weight)

Once an appropriate medication is selected, the pharmacist must determine the proper administration of the drug. The frequency of administration is generally related to the pharmacokinetic properties of the medication. Drug half-life and duration of action allow for many medications to be administered once daily, which will save nursing time and allow for increased patient compliance in most cases. While sustained release preparations allow for decreased administration frequency and are usually preferred, elderly patients receiving nutrition through nasogastric or gastrostomy tubes cannot receive these medications. Liquid medications that do not need to be crushed beforehand are usually preferred for these patients when they are available. Patient-specific pharmacokinetic issues need to be considered, such as impaired renal function. Dosage adjustments for renally administered drugs must often be considered for elderly patients. Concomitant medications that interact with the selected medication may need to be eliminated. They may be continued with a dosage reduction in some cases, and require follow-up monitoring for toxicity and effectiveness.

03.02.05 Packaging the Medication for Use Containers:

consider special needs of older adults avoid packaging that is difficult to open use matte, not glossy use large boldfaced type must be clear and concise state generic or brand name

Labels:

Instructions and Product Information:

display special storage considerations include purpose of medication, dosage schedule, side effects

For the geriatric patient, who is functionally and cognitively able to participate in his or her own treatment regimen, several issues need to be considered to ensure compliance. One of these issues is the selection of appropriate containers. Childproof lids and blister packs tend to be difficult to open for elderly patients with limited manual dexterity. Another issue is how critical information about the medication is communicated. Directions for use and product information must be clear and concise. Medication containers should be labeled with large boldface type for easier reading. Matted labels are preferred over glossy labels. Special storage considerations, such as refrigeration, must be prominently displayed. The generic or brand name of the drug, its purpose, thedosing and potential side effects should be included on the label if possible. In institutional environments such as long term care facilities, these issues are more important to those individuals who are administering the medication. Selected elements may be important to communicate in the rare instance when patient self-administration is allowed.

03.02.06 Explaining the Therapeutic Regimen

Speak slowly, directly and distinctly Limit comments to essential points Invite questions after each point Use examples and demonstrations Help the patient understand illness, drug regimen, and goals Use education, memory and compliance aids
o o o o o

heart-shaped sticker for cardiovascular medications weekly pill reminder electronic pill boxes vial cap drug diary or calendar

In the institutionalized setting, the interdisciplinary health care team, including family members, must have an awareness of the therapeutic regimen to ensure its proper implementation.

If the patient is directly involved in treatment, he or she must be educated accordingly. When explaining the regimen to a patient, speak slowly, directly and distinctly. Limit comments to essential points, and invite questions after each one. Use examples to illustrate when one would take the medication, and demonstrate if appropriate.

Help the patient become knowledgeable about his or her illness, drug regimen, and therapeutic goals, and encourage the use of memory and compliance aids such as a drug diary or calendar.

03.02.07 Sources of Noncompliance

Physical limitations
o o o o o

poor visual acuity impaired hearing decreased manual dexterity memory loss dry mouth

Cognitive limitations Therapeutic effects

o o

incomplete therapeutic regimens adverse drug reactions

Financial constraints Psychosocial factors

o o o

interfering health beliefs influence of family and friends influence of caregivers

Noncompliance with the therapeutic regimen may be influenced by a variety of

factors that include physical limitations, adverse reactions, and health beliefs. These factors are listed on your screen. Awareness of these factors can assist the pharmacist in identifying and reducing potential barriers to successful achievement of therapeutic goals.

03.02.08 Avoiding Adverse Drug Reactions and Interactions

Discuss potential side effects Discourage self-medication of symptoms Encourage reporting of new symptoms Report new prescriptions to providers

The pharmacist must consider strategies for avoiding adverse drug reactions and interactions. These strategies include discussing the potential side effects of medications with patients and discouraging the self-medication of symptoms. Encourage the patient to contact you or his or her doctor if new symptoms develop while following the drug regimen. In the institutional environment, physicians, nurses, ancillary service providers, and family and friends need to be aware of the dangers of adverse drug reactions and self-medication, and the importance of reporting changes in cognitive and functional status. Some side effects are expected with certain medications and strategies for management should be discussed. It is important that all health care providers are aware of the entire medication regimen.

03.02.09 Completing the Therapeutic Regimen and Care Plan

Goals established Interventions agreed upon Responsibilities accepted

Design of a care plan is complete when reasonable goals and expectations are set, interventions are agreed upon, and responsibilities of the practitioner, caregivers, family, and patient are accepted. Once the plan is implemented, the patient must be monitored and evaluated to ensure that therapeutic goals are being met.

03.02.10 Resources For additional information, see: Adamcik, B.A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel ET, Gourley D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Anon. (1993). Guidelines for consultant pharmacists practicing in residential care facilities. Consult Pharm; 8: 150-153. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Delafuente, J.C. & Stewart, R.B., (Eds.) (2001). Therapeutics in the elderly, 3rd ed. Cincinnati: Harvey Whitney Books Company. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association

http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/

Module 3, Section 3: Devising a Therapeutic Monitoring Plan

03.03.01 Steps in Devising a Therapeutic Monitoring Plan Define Needs Identify Goals Design the Therapeutic Regimen Monitor the Patient:

Review therapeutic regimen

o o o o

evaluate plan for safety evaluate patient compliance evaluate plan for effectiveness determine if therapeutic goals are met

Use feedback to revise plan

Document Patient Progress The design of the pharmaceutical regimen and patient care plan represents the beginning, not the end, of the therapeutic planning process. Once treatment has been initiated, both the patient and the therapeutic regimen must be continually monitored for safety and effectiveness. The impact of therapy on the patients quality of life must also be evaluated on a regular basis. At some point a determination must be made as to whether the therapeutic goals have been met. Data gathered during this monitoring period are used to develop recommendations for modifying the plan.

03.03.02 Reviewing the Therapeutic Regimen: Medication Safety

Side effects Adverse reactions Pharmacodynamic and pharmacokinetic interactions Drug-drug interactions Drug-food interactions

Medications incorporated into every patient care plan must be monitored and reviewed on a regular systematic basis. Federal regulations in long term care facilities require monthly drug regimen reviews. Other institutions may have their own review policies. During these reviews, the safety of the medication is evaluated. Side effects and adverse reactions experienced by the patient are noted, along with any potential pharmacodynamic and pharmacokinetic interactions. Direct observations for adverse drug events and laboratory data should be part of the monitoring process.

Which of the following must always be considered when evaluating medication safety? A. B. C. D. E. Drug-drug interactions Patient's ability to self-administer the drug Risk of environmental contamination Bioavailability All of the above

CORRECT ANSWER: A. While all the listed factors are important, drug-drug interactions must be continuously monitored for and anticipated when evaluating medication safety.

03.03.03 Reviewing the Therapeutic Regimen: Patient Adherence Sources of Nonadherence:

physical limitations cognitive limitations incomplete therapeutic regimens adverse drug reactions financial constraints interfering health beliefs influence of family and friends influence of caregivers

Evaluation Strategies:

review of medication administration record comparison of refill record and directions for use monitoring patient for adverse effects

Another area that must be evaluated during the monitoring process is patient adherence. Nonadherence with the pharmacotherapeutic regimen may be influenced by a variety of factors that include physical and cognitive limitations, financial constraints, and psychosocial factors. Assessment of the medication administration record may reveal adherence issues that need to be addressed. For example, an inconsistency between the refill frequency and directions for use suggest an adherence problem. Continuous monitoring for drug toxicities, tolerance, and adverse effects may uncover additional sources of nonadherence.For more information on medication adherence: http://www.adultmeducation.com/

03.03.04 Reviewing the Therapeutic Regimen: Medication Efficacy

Effect of prescribed medications on patients health Effect of unnecessary medications on therapy

The monitoring process should evaluate the efficacy of therapy. Is the agent potentially causing, or contributing to, any significant change in the patients status? Is the patient taking any unnecessary medications that should be discontinued? The risk-benefit of each medication must be evaluated on an ongoing basis, and appropriate actions taken in order to optimize the continuing quality of the therapy. 03.03.05 Evaluating Therapeutic Outcomes STATUS Resolved (acute concern) Goals Achieved Yes Progress Continue Discontinue Yes No Yes New Agent Recommended Comment For acute concerns, drug therapy may be

Stable

Yes

Yes

Yes

No

Improved Partial improveme nt Unimproved Worsened

No Not yet

Yes Some

Yes Yes

Not yet No

Little or none No

Depends No

Depends Yes

Depends Yes

discontinued For chronic maintenance therapy, drug therapy may be continued No substantial drug therapy changes made Minor adjustments in care plan may be indicated to meet goals Depends on timing of evaluation Decline in patients health, may require discontinuation after side effect, drug interaction, noncompliance issues assessed Patient dies while receiving drug therapy

Failure Expired

No No

No No

No No

Yes Yes

Yes No

Integral to the monitoring process is the evaluation of therapeutic outcomes. The chart on your screen illustrates the types of patient status indicators that are important in this evaluation. Data collected during this process one is rolled into a recommendation, and reviewed with the multidisciplinary health care team before instituting changes. 03.03.06 Evaluating Therapeutic Outcomes Vital Signs:

temperature heart rate blood pressure

respiratory rate

Status of Affected Systems:

cardiovascular pulmonary fluid and electrolyte status renal functions hepatic functions endocrine functions gastrointestinal GU/ reproductive musculoskeletal neurological psychiatric/psychological skin EENT nutritional status

Appropriate assessment tools and procedures must be used to evaluate the health status of the patient and the degree to which therapeutic goals have been achieved. The patients vital signs should be assessed frequently, depending on the severity of the disorder and pharmacotherapeutic treatment. A check of systems affected by the disorder and its treatment should also be conducted. These assessment data must be analyzed, translated into recommendations, and reviewed with the interdisciplinary health care team before instituting any changes.

03.03.07 Using Feedback to Revise the Therapeutic Regimen

Document findings Roll findings back into recommendation Adjust if necessary

The results of the evaluation process should be documented on the patients medication record or individualized monitoring form, either in written or electronic

format. This recorded feedback then becomes the foundation for recommendations as to how to modify the therapeutic plan. For example, from documented evidence of adverse effects experienced by the patient, you may conclude that it is necessary to lower the dosage, alter the administration of the drug, or replace the drug with an alternative that is safer and equally effective. All recommendations should be discussed with the interdisciplinary team.

03.03.08 Factors in Determining Monitoring Frequency Therapeutic Factors:

pharmacotherapeutic goal characteristics of the illness characteristics of medication

Specific Needs of:

the patient the family other caregivers

Logistical Considerations:

Cost and reimbursement Practical constraints of monitoring

The final step in the monitoring process is to determine the appropriate monitoring frequency. The time frame between successive follow-ups should be tied to the therapeutic goal, the nature of the illness, and the characteristics of the medication prescribed. The factors shown here should be considered whenever monitoring frequency is in question. 03.03.09 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486.

Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Anon. (1993). Guidelines for consultant pharmacists practicing in residential care facilities. Consult Pharm; 8: 150-153. Bulpitt, C. J. & Fletcher, A. E. (1990). Drug treatment and quality of life in the elderly. Clin Geriatr Med; 6(2): 309-318. Cipolle, R .J., Stroud, L. M., & Marley, P. C. (2004). Pharmaceutical care practice; New York: McGraw Hill. Clark TR, Gruber J, Sey M. The early history and evolution of DRR. Consult Pharm; 2003;3:215-35. Clark TR, Gruber J, Sey M. Revisiting drug regimen review, part II: art or science. Consult Pharm; 2003;6:506-13. Clark TR, Gruber J, Sey M. Revisting drug regimen review, part III: a systematic approach to DRR. Consult Pharm; 2003;8:656-66. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Delafuente, J.C. & Stewart, R.B., (Eds.) (2001). Therapeutics in the elderly, 3rd ed. Cincinnati: Harvey Whitney Books Company. Faden, R. & German, P. S. (1994). Quality of life. Considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 12821290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158.

Websites: American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/ Cytochrome P450 Drug Interaction Table http://www.drug-interactions.com

Module 3, Section 4: Documenting the Pharmaceutical Health Plan

03.04.01 Purpose of Documentation

To record the steps in the therapeutic planning process:

o o o o o

assessment of needs establishment of therapeutic goals design of the therapeutic regimen monitoring and following up schedule achievement of therapeutic outcomes

To promote acceptance of the therapeutic plan To provide a basis for solving health care problems To provide a vehicle for communication among patient, family, and caregivers

Documenting the pharmaceutical care relationship is essential in todays health care environment. All steps of the therapeutic planning process must be documented, from the assessment of patient/family needs and identification of therapeutic goals, to the design of the therapeutic regimen and monitoring plan. Effective documentation using a problem-oriented approach will facilitate plan acceptance, patient-caregiver communication, and achievement of therapeutic outcomes. The time you spend on documenting the pharmaceutical care relationship will aid you and ultimately your patient to resolve his or her health problems. Documentation of the therapeutic plan: A. B. C. D. Is based on a standard problem-solving format Is determined by the healthcare setting Requires the consent of the patient Must be done by hand

CORRECT ANSWER: B. The environment of the healthcare setting where the documentation is occurring will dictate the format in which it is done.

03.04.02 The SOAP Format Identify problem --> Subjective data Quantify data --> Objective data Assess the data --> Assessment Solve the problem --> Plan

The SOAP format provides a problem-oriented method for documenting the pharmaceutical care relationship. SOAP represents a four-step process that consists of identifying the problem with subjective data, quantifying the data objectively with tests if possible, assessing these subjective and objective data and recommending a plan to solve the problem. Each component of the SOAP format is described in the next series of frames. 03.04.03 Documenting Subjective Data

Characteristics of Data:

focuses on patients perspective descriptive in nature can incorporate perspective of family members or other caregivers perspective

Data Gathering Methods:

listening to patient complaints or symptoms listening to family and primary care givers observations asking questions observing the patient

Examples of Subjective Data Collected:

chief complaint (e.g., pain, fatigue, shortness of breath) mental status (e.g., depressed, anxious,happy) medical status (e.g., worse, no change, better)

When you identify the problem using subjective data, you are really asking how the patient feels and observing what you can regarding his or her health condition. Identifying the problem subjectively can help you quantify it objectively in the next step. Subjective data documentation should be descriptive in nature, and may not be verifiable through tests. This type of data is gathered by listening to the patients complaints or symptoms, and questioning the patient on areas such as the duration of symptoms and effectiveness of therapy. While documenting this information, you will also want to note the patients mental status. Listening to the observations of family members or primary caregivers will provide additional critical information regarding the patients physical and mental status.

03.04.04 Quantifying the Data Objectively

Characteristics of Data:

countable measurable

Data Gathering Methods:

physical examination laboratory tests and procedures imaging procedures assessment instruments

Examples of Objective Data Collected:

routine patient data (e.g., vital signs, I/O, weight) signs and symptoms (e.g., frequency of behaviors, number of lesions)

tests (e.g., blood count, liver function, urinalysis) studies (e.g., cytological, tissue, stool, or sputum cultures) imaging (e.g., x-ray, CT scan, MRI)

After gathering subjective data and identifying the medical problem, you will want to quantify the problem objectively using laboratory tests and procedures. These tests and procedures may include assessments of hematologic, hepatic, and renal function. Some drugs may require therapeutic serum concentration monitoring for assessment of dosing adequacy and potential for toxicity. With infected patients, blood tests and cytological studies can facilitate antibiotic selection and eradication of the infecting organism. If you have access to the medical record, note the results of physical examinations and laboratory tests already documented in the plan. Include results of additional tests, procedures and assessments in the plan. Keep in mind that objective data should be countable or measurable, and can include vital signs, height and weight, fluid intake and output, and frequency of targeted signs and symptoms, including behaviors.

03.04.05 Assess the Data

Assess both subjective and objective data Identify etiology of problem

drug-induced disease induced need for current therapy response to current therapy need for additional therapy aggressiveness of therapy needed alternative approaches

Determine:

Once the subjective and objective data have been collected, you must assess the data in order to determine the need for therapy or the patients response to current therapy. Your assessment should provide clues to the cause of the problem. For example, is the patients condition drug-induced? From your assessment you should also be able to determine the aggressiveness of the therapy needed, and whether it should be implemented in place of or in addition to the patients current therapeutic regimen. 03.04.06 Solve the Problem and Document the Plan

Recommend:

continuing therapy discontinuing therapy beginning new therapy

Document:

reasons for recommendations therapeutic goals therapeutic regimen, including:

o o o o

selected medication(s) medication form and route of administration starting and maintenance dosage dosing schedule and duration of therapy

drugs to avoid therapeutic and toxicity monitoring parameters patient/family/other caregiver education follow up plans

Solving the problem involves documenting the therapeutic plan, including recommendations to continue, discontinue or begin therapy, and the reasons behind the recommendations. If new drug therapy is recommended, document the medication of choice, dose and dosage form, route, schedule and duration. Be sure to note the medications to avoid due to allergies or compliance issues.

Treatment goals, therapeutic and toxicity monitoring parameters, patient education, and future plans, as in follow-ups, should also be noted.

03.04.07 Documentation Format

Dictated by setting and administrative policies May be paper-based or electronic

The documentation format is dictated by the practice setting. Some settings for example, have specific policies prohibiting pharmacists to write on the patients chart. If available, the consulting pharmacist should consider using an electronic documentation system for recording therapeutic interventions and outcomes. This format will allow the pharmacist to track patient progress, evaluate the level of success with patient care recommendations, and generate reports for administrative and reimbursement purposes.

03.04.08 The Medication Record Purpose - Outlines relationship between:

patients indication for drug therapy the drug product dosage regimen patients response to therapy

Contents:

all drug products being taken or anticipated for each medication:

o o

the type of medication (e.g., prescription/nonprescription., samples, herbal remedies, vitamins) indication for use (e.g., cure illness, prevent illness, provide comfort, assist in diagnosis, correct abnormal test values)

The medication record outlines the relationship between the patients indication

for drug therapy, the drug product, dosage regimen, and patients response to therapy. It is here that you must list all the drug products that a patient is taking or expected to take. Note in each case the type of medication and whether it is prescription, nonprescription, an herbal remedy, or a vitamin. In each case, you should also document the indication for taking the drug, whether it be for curing an illness, preventing one, or providing comfort from signs and symptoms. 03.04.09 Documenting Outcomes STATUS Resolved (acute concern) Stable Goals Achieved Yes Progress Continue Discontinue Yes No Yes New Agent Recommended Comment For acute concerns, drug therapy may be discontinued. For chronic maintenance therapy, drug therapy may be continued. No substantial drug therapy changes made Minor adjustments in care plan may be indicated to meet goals Depends on timing of evaluation Decline in patients health, may require discontinuation after side effect, drug interaction, noncompliance issues assessed Patient dies while receiving drug therapy

Yes

Yes

Yes

No

Improved Partial improveme nt Unimproved Worsened

No Not yet

Yes Some

Yes Yes

Not yet No

Little or none No

Depends No

Depends Yes

Depends Yes

Failure Expired

No No

No No

No No

Yes Yes

Yes No

When documenting therapeutic outcomes, determine the appropriate status as shown here. Roll feedback into plan, adjusting if necessary and documenting changes. 03.04.10 Resources For additional information, see: Adamcik, B. A. & Rhodes, R. S. (1993). The pharmacist's role in rational drug therapy of the aged. Drugs Aging; 3(6): 481-486. Anderson, R. J. & Miller, S. W. (1992). Geriatric drug therapy. In: Herfindel, E. T., Gourley, D. R. & Hart L. L., (Eds.). Clinical Pharmacy and Therapeutics, 5th ed. Baltimore: Williams & Wilkins, 1489-1507. Anon. (1992). Guidelines for consultant pharmacists practicing in nursing facilities. Consult Pharm; 7: 1094, 1099. Cipolle, R .J., Stroud, L. M., & Marley, P. C. (1998). Pharmaceutical care practice. New York: McGraw Hill. Delafuente, J. C. (1991). Perspectives on geriatric pharmacotherapy. Pharmacotherapy; 11(3): 222-4. Faden, R. & German, P. S. (1994). Quality of life. considerations in geriatrics. Clin Geriatr Med; 10(3): 541-51. Feinberg, J. L. (1991). Taking responsibility for therapeutic outcomes:barriers to consultant pharmacists. Consult Pharm; 6(12): 958-965. McKenzie, L. C., Kimberlin, C. L., Berardo, D. H., Pendergast, J. F. (1991). Pharmacists care of elderly patients. University of Florida, College of Pharmacy. Torg, E. (1992). Life since OBRA: roles and responsibilities of consultant pharmacists and physicians in long-term care. Consult Pharm; 7(12): 1282-1290. Wong, B. J., et al. (1994). Role of the pharmacist on a geriatric assessment team. Consult Pharm; 9(10): 1149-1158. Websites:

American Society of Health-System Pharmacists http://www.ashp.org American Society of Consultant Pharmacists http://www.ascp.com American Pharmacists Association http://www.aphanet.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/