Transcript self care part 2 .pptx

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Self care
Lecture 2
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Patient
Assessment &
Consultation
Ghadah Asaad Assiri
23/April/2014
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Outline
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Medication therapy management (MTM)
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MTM in self care setting
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QuEST/SCHOLAR-MAC process
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Fever case study
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Fever definition , pathophysiology , etiology ,
complications
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S
O
A
P
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Self care
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Medication therapy management (MTM ) :is a service or
group of services that optimize therapeutic outcomes for
individual patients.
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Pharmacists provide medication therapy management to
help patients get the best benefits from their medications
by actively managing drug therapy and by identifying,
preventing and resolving medication-related problems.
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Why is MTM is needed?
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Medication-related problems and medication mismanagement
are a massive public health problem in the United States.
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Experts estimate that 1.5 million preventable adverse events
occur each year that result in $177 billion in injury and death.
APhA MTM Central,2014
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Goal of Pharmacist Providing
MTM
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To make sure that the medication is right for the patient
and his or her health conditions and that the best possible
outcomes from treatment are achieved.
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Indicated
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Effective
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Safe
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Compliance
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Economy
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Self care setting
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The patient care process as it pertains to medication
therapy management (MTM) includes :
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Assessment
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Care plan
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Follow up & Evaluation
One of the process to evaluate a patient self care needs &
drug related need :
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QuEST/SCHOLAR-MAC method
Self care institute of the AphA
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QuEST
Consultation process
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Quickly and accurately assess the patient
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Establish that the patient is an appropriate self-care
candidate
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Suggest appropriate self-care strategies to the patient
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Talk with the patient about the selected self-care strategies
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QuEST/ SCHOLAR
Subjective information
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Symptoms: what are the main & associated /related symptoms ?
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Characteristic :what are the symptoms like?
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History : what has been done so far ? Has this ever happened & what
was successful ?
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Onset : when did this particular problem start?
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Location : where is the problem ?
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Aggravation factor :what makes it worse ?
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Remitting factors : what makes it better ?
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QuEST/SCHOLAR-MAC
Assessment
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Medication : prescription , nonprescription and natural
product
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Allergies : medications and other type of allergies
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Conditions :other medical conditions
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Case-Fever
pt
 LD
is a 5 years old female , 4 ft 2 in , 50 Ib. her
babysitter noticed the toddler hadn’t eaten any
dinner or had anything to drink except a couple
tiny sips of apple juice that the baby sitter forced
into her , no diarrhea/ vomiting .
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when LD’s parents returned from the theater around
midnight , they used a tympanic thermometer to take
LD’s temperature , which was 103.4 F. LD again
refused to drink any fluid . Her mom rushed out to the
pharmacy because her provider’s office was closed
 Diet
:usually has a big appetite. Sleep : normal
sleep pattern
 Allergies
: penicillin
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Fever – Definition
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Fever is a common reason for visit to pediatrician offices .
Fever is the leading cause of visits to the ER for children < 15 years
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Children have > reported fevers compared to adult
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Fever : is defined as body temperature > normal core temperature of
37.8C .Regulated rise in body temperature maintained by the
hypothalamus in response to a pyrogen
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Hyperthermia : malfunctioning of the normal thermoregulatory
process at the hypothalamic level
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Hyperpyrexia a body temperature >41.1 C that typically result in
mental and physical consequences .May result from pyrogen or
hyperthermia
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Fever- Pathophysiology
pyrogen
(Trigger)
• Bacteria –
infection
• Drug/ toxin
• Virus
• Immune
complex
Leukocytes
(fever
producing
substance )
• IL-1
• IL-6
• TNF
Anterior
hypothalamus
(thermostat)
If malfunctioning
hyperthermia
Hyperpyrexia
> 41.1 C
Thermosensitive
neurons in
skin & CNS
(Set-point)
• Fever (> 37.8)
• Chills ( if temp
< set point )
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Fever – Causes & Complications
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Causes
Pyrogens: e.g: bacteria ,
virus , Drugs :
1.
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•
•
•
•
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Altered thermoregulation
Pharmacologic action
Drug administration
Hypersensitivity
Idiosyncrasy
Abnormal metabolism
(immune complex,
hypothalamus )
Most fevers are self limiting
and rarely poses sever
consequences except if:
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Infection is a primary concern
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Febrile Seizure (infant,
children)
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Dehydration , coma,
irreversible neurological or
muscle damage
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Allergy (rash , spots)
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Hyperpyrexia :The body
temperature >41.1C
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Fever – Subjective
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Elevated temperature
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Accompanied with discomfort :Headache , generalized
malaise , chills , tachycardia , arthralgia , myalgia ,
irritability , anorexia.
+ Information Gathering: (1) Symptoms
Pt
Symptoms: Description (e.g., Characteristic , nature, duration, severity,
associated symptoms)
History ( e.g., travel
history )
Onset
Location
Aggravation factor :Description of any factors that seem to participate,
exacerbate, and/or relieve the patient's symptom(s)
Remitting factors :Description of the patient's efforts to relieve the
symptoms
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(2) Patient History Information: Pt
Patient's identity
Patient's age, sex, height, and weight
Patient's occupation
Patient's dietary habits
Patient's sleep habits
Medications :prescription and nonprescription medications, and dietary supplements.
Allergies
Concurrent medical conditions
History of other adverse reactions to medications
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Fever – Objectives
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Body Temperature Measurement
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Fever should be confirmed only by using a thermometer which is
an FDA-regulated medical device.
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Core temperature is estimated with various types of thermometer
used :
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Rectal temperature measurement using electronic thermometer
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Oral temperature measurement using electronic thermometer
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Digital probe
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Digital pacifier thermometer
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Axillary temperature measurement using electronic thermometer
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Tympanic temperature measurement
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Temporal Artery temperature measurement
Factors affecting the type of thermometer :
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site of measurement , age ,availability, preference , convenience
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Body Temperature Measurement
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Do not rely on feeling the body to detect fever .Take a temperature
reading with an appropriate thermometer.
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Monitoring ( during febrile illness ): Body temperature should be
measured with the same thermometer at the same site over the course of
an illness since the reading from different thermometer or sites may vary
X 2-3 /d
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Children < 6 months -infant
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Children >6 months –infant :
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Rectal method of temperature measurement is preferred.
Children 6 months – 5 years –early childhood :
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Use of a tympanic thermometer is not recommended because of the size and shape of
the infants ear canal
Rectal method is preferred
Oral, tympanic ,temporal may be used if proper technique is followed
Individual > 5 years –child ,adolescences , adult
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Oral , tympanic , temporal method is appropriate
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Body Temperature Range based
on Site of Measurement
Site of measurement Normal range( C)
Fever (C )
Rectal
36.6 -38
>38
Oral
35.5 -37.5
>37.5
Axillary
34.7- 37.4
>37.4
Tympanic
35.7 – 37.8
>37.8
Temporal
36.6 -37.8
0-2 mo old 
>38.1
3-47 mo old >37.9
> 4yr old 
>37.8
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Assessment
(3) Differentiate the patient's signs/symptoms and
correctly identify the patient's primary problem(s).
Pt
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Assessment
(4) Identify exclusions for self-treatment
Pt
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Exclusions for self care –Fever
Patient > 6 month of age with rectal temperature of ≥ (40
C) or equivalent (oral temp ≥ 37.8 C)
Children < 6 month of age with rectal temperature of ≥
38 (oral temp ≥37.8 C)
Sever symptoms of infection that are not self-limiting
Risk of hyperthermia
Impaired O2 utilization (e.g., sever COPD , respiratory
distress , heart failure )
Impaired immune function (e.g., cancer , HIV)
CNS damage (e.g., head trauma, stroke )
Children with history of febrile seizure or seizures
Fever that persist > 3 days with or without treatment
Child who develops spots or rash
Child who refuses to drink any fluid
Child how is very sleepy , irritable or hard to wake up
Child how is vomiting & can’t keep down fluids
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Assessment
Pt
(5) Formulate a comprehensive list of therapeutic
alternatives for the primary problem to determine if referral
to a medical practitioner is required, and share this information
with the caregiver.
+ Assessment- Therapeutic Alternative
OTC class
e.g
Analgesic/antip Acetamiyretic
nophen
-Reduce temp.
-Help alleviate
discomfort
associated with
fever
Dose
Onset
Adult 500mg-1 g ½ -1 hr
q 4-6 hr PRN /day
.Max 4g/day
Pediatric :1015mg/kg q 4-6 hr
PRN .
Max. 4g/day
Comment
*Low dose x3days
Unless there is
exclusion to self
care
*If children dosing
/weight
+ Assessment- Therapeutic Alternative
OTC class e.g
Dose
Onset
NSAID
NSAID
Analgesic ,
antipyretic
,antiinflammator
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Comment
Avoid if pregnant
,or
Uncontrolled HTN,
HF , RF ,Risk of GI
ADR
Ibuprofen
Adult : 200-400 mg
q 4-6 hr Max.
1.2g/day
Pedia > 6 month : 510 mg/kg q6-8 hr
PRN .Max 1.2g/day
30 minutes
Approved for
individual > 6
month
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NSAID
Analgesic
Naproxen
Adult :220 mg q8-12
hr .Max :660mg /day
30 minutes
Lowe dose in older
age
rapid
Avoid in Children <
15 yr old and
possible viral
infection because
of possible risk of
Reye’s syndrome
If > 12 yr :220-440 mg,
then 220mg
q8-12 hr .Max
660mg/day
If < 12 yr X
NSAID
Salicylates
Analgesic
+Antiplatelet
ASA containing
product
Adult :650mg-1g q4-6
hr .Max 4 g /day
Pedia :10-15 mg/kg
Freq. as directed by
Dr.
Max. 4g/day
Salicylates
-Analgesic:
mild to
moderate
pain
-Supplement
Magnesium
salicylate
Adult ; 650 mg q4hr
Or 1 g q 6hr
Max. 4g/day
Avoid if allergy to
ASA
rapid
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Acetaminophen Vs Ibuprofen
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Efficacy Vs. safety .
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Ibuprofen is slightly more effective than acetaminophen, longer
duration of action
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The Same risk of SE after multiple dosing
Altering different antipyretic for fever reduction has now
become a wide spread practice
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The American Academy of Pediatrics dose not recommend
alteration of antipyretics because of the risk of overdose, medication
error , resulting from the complexity of the regimes & increase SE .
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Immunization & Antipyretics
Vaccine
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Prophylactic dose before and immediately after vaccination
(controversies )
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widespread practice to reduce discomfort and fever
http://www.pharmacist.com/ask-experts-immunization-anduse-antipyretics
+ Assessment- Therapeutic Alternative
Complementary therapies :Nutritional dietary supplements
e.g. vitamins , minerals & herb
There is insufficient evidence to recommend any dietary
supplement or other complementary therapy for fever.
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Assessment- Alternative
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Non pharmacological :
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Avoid using isopropyl or ethyl alcohol for body sponging
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For all levels of fever , wear lightweight clothing , remove
blanket & maintain room temperate at ≈20 C.
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Alcohol poisoning can result if skin absorption or inhalation
Use hypothermic cooling blanket is discouraged
For Hyperpyrexia : tepid water path is effective
Unless advised otherwise , drink or provide sufficient
fluids to replenish body fluid losses ( water , juice ,
electrolyte formulations)
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Plan
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Pt
Treatment goal :
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Relieve the discomfort of fever by returning the body
temperature to the normal level
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Eliminate the underlying causes.
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Prevent complication associated with fever
(6) Select an optimal therapeutic alternative to address the
patient's problem, taking into account patient preferences.
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Plan
Pt
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(7)Describe the recommended therapeutic approach to the
care giver.
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(8)Explain to the caregiver the rationale for selecting the
recommended therapeutic approach from the considered
therapeutic alternatives.
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Patient (or parents) should be educated on the proper
measurement techniques with the thermometry they utilize
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Syringe, dosing spoon , medicine cup (liquid Mx )
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Clinical Pharmacist care plan :
Oral or sound care plan for a patient in self care setting :
1- Collect additional information :
Preexisting medical condition ,
Ask other health care provider about referral ,
Information on reasons of referral .
2 – Refer a patient to a primary care provider. when ?
If fever or discomfort persist or worsens after 3 days of drug treatment.
Age <6 month + rectal temp≥ 38 C
> 6 month +Rectal temp. is ≥40 C ,
Oral temp ≥37.8 C .
History of febrile seizure,
Comorbid conditions ,
3- Select and evaluate the success of self treatment , if appropriate .
Temp. , discomfort
4- Advice the patient about self treatment .
5- Evaluate progress toward achieving stated goal .
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Patient education
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(9) When recommending self-care with nonprescription
medications and/or nondrug therapy, convey accurate
information to the caregiver:
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Appropriate dose and frequency of administration
Maximum number of days the therapy should be employed
Product administration procedures
Expected time to onset of relief
Degree of relief that can be reasonably expected
Most common side effects
Side effects that warrant medical intervention should they occur
Patient options in the event that condition worsen or persists
Product storage requirements
Specific nondrug measures
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Follow up
Pt.
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(10) collect follow-up questions from caregiver.
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Pt. : I have ibuprofen liquid at home , is that ok to give in
place of the acetaminophen ?
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(11) Answer caregiver's questions.
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Conclusion
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Pharmacist require excellent consultation & communication
skills in order to be effective in eliciting information from the
patient
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When prescribing : first line treatment should have proven
efficacy
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Special consideration apply for children , elderly , pregnant
women .
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Questions
?