The area of pharmacy concerned with the science and practice of rational medication use. (Patient oriented)
Where to practice clinical pharmacy
Hospitals
Community pharmacies
Nursing homes
Home-based care services
Clinics
Any other setting where medicines are prescribed and used
The term "clinical" does not necessarily imply an activity implemented in a hospital setting
Qualifications to be an expert clinical pharmacist
Clinical Pharmacy Fellowship
Board of Pharmacy Specialties
Clinical Pharmacy Diploma
PharmD
Clinical pharmacy Master, and PhD
Clinical pharmacy Bachelor
Responsibilities of a clinical pharmacist in outpatient care
Medication reconciliation
Adjust medication doses as necessary
Improve patient compliance
Report medication errors
Educate patients and providers about medications
Drug information center (DIC)
Provision of specific comprehensive drug information upon request from healthcare providers, and consumers from the general public in a timely manner, based on a complete analysis of available evidence
Maintenance of resources to provide the most current and accurate information to inquirers
Publishing a drug information newsletter
Educating pharmacy students, and professionals about resources and medical literature analysis and enhancing the skill of accurately communicating response (both verbally and in-writing)
Ward clinical pharmacist role
Involved in medical rounds with the other health care professionals
Documenting patient information on a specially designed record
Creating a pharmaceutical care plan
Identify Medication related problems
Answering Medication information queries to physicians & other health professionals
Patient education and counseling
Pharmaceutical care plan
A written, individualized, comprehensive medication therapy plan based on clearly defined therapeutic goals
The pharmaceutical care plan, which is available to all pharmacists caring for a patient, is updated with each major change in patient status
It is important that the physician be informed about the care plan to ensure common goals
Patients should also be informed about the general content of the care plan as means of gaining their agreement regarding drug therapy
Information included in the patient database for the pharmaceutical care plan
Patient demographics
Diagnoses and past medical history
Present medications and medication history
Medication allergies/intolerances
Smoking/alcohol/caffeine/drug use history
Abnormal laboratory and physical exam results
Renal and liver function
Types of drug-related problems
Not receiving an indicated drug
Receiving the wrong drug
Receiving too little of the drug (Subtherapeutic dose)
Receiving too much of the drug (Supratherapeutic dose)
Experiencing an adverse drug reaction
Experiencing a drug interaction
Not receiving the prescribed drug
Drug without indication
Therapeutic goals
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
Educate the patient about his or her medication
Monitoring parameters must also include potential adverse effects
General steps in creating a pharmaceutical care plan
Create comprehensive patient database
Assess for actual and potential drug-related problems
Establish therapeutic goals
Specify monitoring parameters with end points and frequency
Document the patient's progress towards therapeutic goals
Items in the drug checklist for the ICU
Drug interactions
Medication without indication
Right dose
Dosage adjustment according to hepatic and renal functions
Right preparation and administration
Monitoring ADR
Monitoring of treatment response
Lab values monitoring
Indication without medication
Stress ulcer prophylaxis
DVT prophylaxis
Feeding
Analgesia and Sedation
Head of bed elevation
Glycemic control
Risk rating scale for drug interactions
A, B, C, D, X
Use of antibiotics in case of viral infections is an example of medication without indication
The dose of enoxaparin for VTE prophylaxis in critically ill patients is 40 mg SC daily
The dose of enoxaparin for treatment of VTE is 1 mg/kg q12hr or 1.5 mg/kg q24hr
Equations for dosage adjustment in renal impairment
Acute Renal Failure: JELLIFFE multi-step
Chronic Renal Failure: Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
Some drugs require special equations to calculate dosage in renal impairment
Examples of drugs adjusted according to Child-Pugh score