RJAV - ClinPharm

• Clinical Pharmacy


  A health science discipline in which pharmacist provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention
• Responsibilities of Clinical Pharmacy


  • Rational selection
  • Monitoring
  • Dosing
  • Control of the patients' overall drug therapy program
• Pharmaceutical Care


  A cooperative, patient-centered system for achieving specific and positive patient outcomes from the responsible provision of medicines
• Medicines optimization


  Aims to ensure that the right patients get the right choice of medicine at the right time. The purpose is to help patients take their medicines appropriately and, by doing so, avoid unnecessary treatment, improve safety and outcomes, and reduce wastage
• Characteristics of Clinical Pharmacy


  • Not product oriented but patient oriented
  • Primary objective: rational drug use
  • Practice in both community and hospital setting
  • Multidisciplinary
• Rational Drug Use


  Requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community
• Aspects of Rational Drug Use


  • Right drug
  • Right disease
  • Right dose
  • Right dosage form
  • Right dosing schedule
  • Right route
  • Right cost and patient
• Over-the-counter (OTC) drugs


  Drugs which are safe and effective for use by the general public without doctor's prescription. They are primarily used for symptomatic relief and not as substitutes for prescription drugs
• Examples of OTC pain relievers


  • Paracetamol or acetaminophen
  • NSAIDs
• Using Paracetamol


  • Taking a higher dose than recommended will not provide more relief and can be dangerous
  • Overdose of paracetamol can lead to necrosis and death
  • Infant drops can be significantly stronger than regular children's medications
• Using NSAIDs


  • With NSAIDs, too much can cause stomach bleeding and risk is increased in people over 60 years of age, concurrently taking blood thinners, steroid and other drugs which can cause GI irritation, and who have history of stomach bleeding or ulcers
  • For children, naproxen sodium ≠ children under 2 years of age
  • Ibuprofen is considered safe for children 6 months and older in the right dose
  • Before taking NSAIDs, consider if over age 60, taking diuretic, have high BP and heart disease, with re-existing kidney disease, or children and teenagers who are recovering from a viral infection
• Using Cough medicines


  • Avoid using the cough preparations for more than 7 days
  • Use only the correct dose. High doses of preparations can cause serious problems such as brain damage, seizure or death
  • Use the correct dose for children. For ages 4-6, ask the doctor first. And don't give to children under age 4
• OTC drugs are safe but not risk-free
• Examples of OTC drugs that can severely habit-forming


  • Decongestants
  • Laxatives
  • Antihistamines
  • Sleep aids
  • Antacids
  • Ephedrine
• Clinical Pharmacy Settings


  • Hospitals
  • Community pharmacies
  • Nursing homes
  • Home-based care services
  • Clinics
  • Any other setting where medicines are prescribed and used
• Scientific Principles Applied in Clinical Pharmacy


  • Pharmacology
  • Toxicology
  • Therapeutics
  • Clinical pharmacokinetics
  • Pharmacoeconomics
  • Pharmacogenomics
• Pharmaceutical Care Process - Assessment


  • Assess the patient for drug-related problems
  • Determine whether drug-related problems are being treated
  • Determine whether current drug therapy is appropriate
  • Determine whether additional drug therapy is needed
  • Determine if any of the drug-related problems may have been caused by medication
• Pharmaceutical Care Process - Care Plan


  • Approach normal physiology (i.e., normalize blood pressure)
  • Slow progression of disease (i.e., slow progression of cancer)
  • Alleviate symptoms (i.e., optimize pain control)
  • Prevent adverse effects
  • Control medication costs
  • Educate the patient about his/her medication
• Pharmaceutical Care Process - Evaluate of outcome


  • Specify patient's progress
  • Monitor potential adverse drug reactions
  • Determine desired end points for each parameter and the frequency of monitoring
• Outcomes of Pharmaceutical Care


  • Minimizing or eliminating patient's symptoms
  • Modifying or curing of disease process
  • Improve the prognosis of patients
  • Identifying and resolving drug related problems
  • Preventing drug misadventures
• Knowledge and Skills of Clinical Pharmacist


  • Expert knowledge on drug and non-drug therapy
  • Knowledge on lab and diagnostic test
  • Good understanding of disease process
  • Physical assessment skills
  • Therapeutic planning skills
  • Drug monitoring
  • Provision of drug information
  • Communication skills
• Roles of a Clinical Pharmacist


  • Interact with health care team (MD, RN, paramedics)
  • Interview and assess patient (patient medication history)
  • Review medication order and make therapeutic recommendations
  • Monitor patient response to drug therapy
• Patient Medication Profile (PMF)


  Written summary of all the medicines taken regularly, including over-the-counter and complementary medicines. Assist to understand and manage medicines by informing how, why and when to take medicine
• Medication Reconciliation Process


  The process of creating the most accurate list possible of all medications a patient is taking – including drug name, dosage, frequency, and route – and comparing that list against the physician's admission, transfer, and/ or discharge orders, with the goal of providing correct medications
• Patient Medical Chart (PMC)


  Contains all significant clinical information which enables the physician to give effective continuing care to the patient. Used as basis for drug therapy plan for patient
• Parts of Patient Medical Chart


  • Patients Data Sheet
  • Consent form
  • History
  • Physical Examination
  • Physician's order sheet
  • Consultation, Examination and Findings
  • Graphic chart
  • Fluid input and output record
  • Medication Administration record
  • Multidisciplinary Progress Notes
  • Laboratory results
• Components of History


  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Medical History (PMH)
  • Family History
  • Social history
  • Review of Systems (RoS)
• Vital Signs


  • Body Temperature
  • Pulse rate
  • Respiratory rate
  • Blood pressure
• Body Temperature


  • Can be measure in oral, rectal, axillary, tympanic. Abnormal findings: Hyperthermia, Hypothermia
• Pulse rate


  • Radial pulse – most easily accessible, Femoral or carotid pulse – palpitate in emergency cases. Abnormal findings: Irregular pulse rhythm – Bradycardia, Tachycardia
• Respiratory rate


  • Abnormal findings: Prolonged expiration suggesting narrowing in bronchioles (asthma), Sounds: wheezing or stridor, Apnea – no breathing, Bradypnea – abnormally slow, Tachypnea – abnormally fast
• Blood pressure


  • Abnormal findings: Hypertension, Cardiac disease – difference of 15mmHg or more between arms, Orthostatic hypotension – drop of 20 mmHg or more from sitting to standing position, Venous congestion or hypertension – silent period (auscultatory gap between systolic and diastolic sounds)
• IPPA Physical Assessment Techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• SOAP Documentation


  • Subjective - Information from the patient's statement, Non-reproducible
  • Objective - The observations of the physician during the examination and the laboratory results, Measurable and reproducible
  • Assessment - The impression of the patient's problem that leads to diagnosis
  • Plan - The treatment plan to correct the illness or problem
• Medication order review by pharmacists is a multistep process in which pharmacists evaluate orders (prescriptions) for safety, efficacy, and appropriateness by examining drug-and patient-related factors
• Factors Examined in Medication Order Review


  • Drug interactions
  • Adverse drug reactions
  • Medication errors
• Documentation


  Means by which healthcare professionals communicate with one another
• Components of SOAP documentation


  • Subjective
  • Objective
  • Assessment
  • Plan
• Subjective


  Information from the patient's statement
• Objective


  • The observations of the physician during the examination and the laboratory results
  • Measurable and reproducible