▪ •Pharmaceutical Care
▪ •Pharmaceutical Care Plan
▪ •Designing and implementation
TABLE OF ▪ •Application Of pharmaceutical Care Plan
CONTENTS: ▪ •Issues in Pharmaceutical Care.
▪ •Literature review
•Pharmaceutical care was probably first defined by Mikeal et
al. in 1975 as ‘the care that a given patient requires and
receives, which assures safe and rational drug use’.
•Hepler, in 1988, described pharmaceutical care as
‘a covenantal relationship between a patient and a
practitioner in which the pharmacist performs drug
use control functions governed by the awareness of
and commitment to the patients’ interest
•The widely accepted definition by Hepler and Strand states
‘Pharmaceutical care is the responsible provision of drug therapy
for the purpose of achieving definite outcomes that improve a
patient's quality of life’
Pharmaceutical care involves the process through which
pharmacist cooperates with patient and other professionals
in designing ,implementing and monitoring a therapeutic plan
that will produce specific therapeutic outcomes for the patients.
Elimination or Arresting or
Cure of Prevention of a
reduction of a slowing of a
patient's disease or
patient's disease
disease symptom.
symptoms. process
▪ Optimize the quality of life of patients and attain the positive outcomes and provide
rational use of medications.
▪ To procure these goals the following should be accomplished:
➢ Maintain and establish a professional relationship
➢ To get patient specific medical information.
▪ •Pharmaceutical care plan (PCP) is a patient - centered systematic approach.
Clinical pharmacist design a written format to ensure proper drug use,
achieve a definite outcome and improve patient care through assuring the
safety, effectiveness and cost-effectiveness.
• PWDT Form (Pharmacist workup for drug therapy)
❖ CORE.
❖ PRIME
❖ FARM
❖ SOAP Analysis
▪ •Identifying potential and actual drug related problems
▪ •Resolving actual drug-related problems
▪ •Preventing drug-related problems
ESTABLISHMENT OF PATIENT
DATA-BASE(DATA COLLECTION)
• Patient’s demographics (age, sex, height, weight,…..)
• History of present illness and past medical history
• Family History.
• Present medication and medication history
• Drug allergy and intolerance
• Smoking, alcohol, caffeine and drug abuse history
• Physical examination and abnormal laboratory results
including renal and hepatic function
• Patient complaints: Signs and symtpoms.
▪ C= Condition
May be non-medical related or need of patient
▪ O= Outcome
Patient outcome
Therapeutic end point
▪ R= Regimen
Therapeutic Regimen
▪ E= Evaluation
Evaluation parameter to access outcome achievement.
IDENTIFICATION OF DRUG
RELATED PROBLEMS:
• Goal is to identify the
▪ Actual: A condition that requires the initiation of a new or
additional drug.
▪ Potential: Patient may be at a risk to develop a new medical
problem.
• These problems may be related to patient's current drug
therapy ,drug administration, drug compliance, drug
toxicity, drug ADRs and a failure to achieve desire outcomes
by the treatment.
• It is used to identify the PRIME pharmacotherapy problems.
▪ P= Pharmaceutical based problem.
o Patient not receiving a prescribed drug,device or intervention
▪ R= Risk to patient
o Adverse Drug reaction
o Allergies
▪ I= Interactions
o Drug –Drug,Drug-disease,Drug-lab
▪ M=Mismatch between medication,condition or patient need
o No indication for current drug,device or intervention
o Indication present but no drug,devcice or intervention prescribed
▪ E=Efficacy issues
o Wrong drug,device,intervention or regimen prescribed
o Sub therapeutic dose
o Toxic dose
Untreated indication(E.g INZ require Vitamin B6 to avoid peripheral neuropathy)
Improper drug selection(E.g nitroglycerin patches for angina pt to be applied on daily
basis)
Sub-therapeutic dosage
Failure to receive medications(due to cost reasons,non-adherence)
Overdosage
Adverse drug reaction(vancomycin cause Infusion related ADR)
Drug interaction (Ceftriaxone with Ca containing IV fluids)
Medication use without indication
DEVELOPMENT OF THERAPEUTIC GOALS:
▪ Therapeutic goals must be developed for each problem. Goals
should be definite, realistic, and measurable if possible.
Therapeutic goals mostly related to:
• Approach normal physiology as normalizing blood pressure.
• Slow disease progression as in cancer.
• Alleviate symptoms (i.e., optimize pain control).
• Prevent adverse drug reactions.
• Consider medication costs.
• Educate the patient about drugs.
▪ Safety, Efficacy, availability, Cost of therapy and suitability of treatment to the patient
should be considered while evaluating.
▪ The risk to benefit ratio factors should also be considered such as
• Seriousness of disease
• Consequences of not treating the disease
• Efficacy of drug.
• ADRs effect related to drug therapy
INDIVIDUALIZING DRUG REGIMEN
Patient factor Drug factor
✓ Diagnosis ✓ Efficacy
✓ Treatment goals ✓ Adverse effect
✓ Physiological and pathological factors ✓ Dosage form
✓ Past medical and medication history ✓ Cost
✓ Contraindication ✓ Drug-Drug interactions
✓ Allergies ✓ Pharmcokinetics and pharmacodynamics
✓ Compliance
▪ Monitoring of outcomes
▪ The prescribed drug or combination of drugs require laboratory monintoring,eg
narrow therapeutic index medication such as gentamycin,warfarin
▪ The prescribed drug or combination of drugs requires laboratory monitoring of
patient parameters eg renal function if taking digoxin ,vancomycin
▪ Consider when monitoring should occur,and how often.
▪ Inappropriate monitoring is often cited as one of the major cause of treatment
failure.It leads to failure to detect and resolve inappropriate therapy decision and a
failure to monitor the drug with narrow therapeutic index.
▪
▪ Documentation provide a record of care provided and history of decision made for
specific patient.
▪ IF IT IS NOT DOCUMENTED,IT IS NOT DONE
▪ Documentation of Pharmaceutical care formulate a Farm note or SOAP note to
document the intervention provided by the pharmacist.
▪ F= Finding
• (patient specific information, Subjective and objective information of patient)
• Pharmacotherapy problems
▪ A= Assessment
• Any additional information that is needed
• The severity, priority or urgency of problem
• Short term and long terms goals
▪ R= Resolution
• Intervention plan include actual or proposed action to be taken:
• Counseling or educating the patient
• Informing the prescribers
• Making recommendation to prescribers
• Withholding the medicine or advising against use.
▪ M= Monitoring
▪ The parameters to be followed(pain,Serum Potassium level)
▪ The intent of monitoring (ADRs,Toxicity)
▪ How parameters will be monitored (physical examination,Lab tests)
▪ Frequency of monitoring (weekly,Monthly)
▪ Duration of monitoring (until resolve, while on antibiotic)
SOAP FORMAT DATA:
•S: Subjective: patient’s chief complain or why came to hospital
•O: Objective: traceable facts as vital signs, lab results, blood
pressure
•A: Assessment: the medical diagnosis on the given date
•P: Plan: treatment plan including drugs, lab orders, referrals.
▪ A patient xyz presented with complains of Nocturia,Polyuria,polydipsia,severe
cough and weight gain over the past year.she was diagnosed with diabetes
Mellitus type 2.she was also hypertensive,obese and has a family history of
Dyslipidemia,Diabetes and hypertension.It has been 21 year of her marriage,she
got divorced.She was non-smoker and drinks 3 wine/week.Her Fasting blood
glucose level is 170mg/dl.
Prescription include;
▪ Tab Lisinopril 20mg PO OD
▪ Tab Glyburide 5mg PO OD
▪ Tab Atorvastatin 20mg PO OD
▪ F= A patient xyz presented with complains of Nocturia,Polyuria,polydipsia,severe
cough ,weight gain.She was diagnosed with Diabetes type 2
▪ A= Assessment
Short term goals:
▪ Reduce blood glucose level .Maintain Fasting blood glucose level 80-12mg/dl and
Random Blood Glucose Level (80-!40),HbA1c<7.
▪ Maintain BP 130/90mmHg
▪ Reduce weight
▪ Reduce Level of LDL and Cholestrol
▪ Long term Goals:
➢ Prevent mircovascular complications (Retinopathy,Nephropathy,Neuropathy) and
Macrovascular complications.(Stroke,MI)
➢ Improve quality of life
➢ Avoid severity of disease.
▪ R= Resolution
As glyburide’s side effect is weight gain.so recommendation is to switch it to
Metformin 500mg TID.which is useful for weight loss and to add another oral
hypoglycemic from other class to control BLood sugar level (Gliptins)
Patient is complaining of severe cough.Lisinopril cause severe cough switch it to
ARB.and add Ca channel blocker to therapy to control BP.
Counsel about diet plan and exercise.
Educate about foot care
▪ M=Monitoring
Monitor BP and blood sugar level regularly
Monitor weight
▪ It is established for helping and improve the good and safe use of medication.
▪ Often the benefits of medication/drugs cannot be realized in patient (due to
treatment failure),and even worse considerable mortality and morbidity are
related to the inappropriate use of medicine use.These medication Errors can be
minimized by pharmaceutical care plan.
▪ It helps to the optimization of outcome from medicine and the prevention of harm
and inappropriate use.
▪ This is acheived through the promoting of medication-related literacy,the
participation and involvement of patient in their medication and acceptance of
responsibilities.This improve patient quality of life,the utilization of resources and
help reduce errors in healthcare.
▪ By Providing cost-effficiency of medicine use,pharmaceutical care will contribute
to efficient and effective consumption of existing resources.
▪ Medication adherence can be improved by updating the knowledge of patients.
▪ Dispensing errrors can be prevented by clinical pharmacists through
pharmaceutical care plan.
▪ Patient assessment
▪ Patient specific-Pharmacist care plan
▪ Drug treatment protocol
▪ Dose adjustment
▪ Selection of therapeutic alternatives
▪ Patient Education and counseling
▪ Background:
The role of a pharmacist in primary health care settings of Pakistan is still obscure. Thus,
we aimed to demonstrate the pharmacist-led improvements in glycemic, blood pressure
and lipid controls in type 2 diabetes mellitus (T2DM) patients of Lahore, Pakistan.
▪ Methods:
Randomized control trial conducted at a primary health care facility of Lahore, Pakistan
by enrolling 244 uncontrolled type 2 diabetes (hemoglobin A1 c, (HbA1c); 10.85 ± 1.74)
patients. The pharmacological intervention included identification of drug related
problems, drug interactions, change in dose, frequency and therapy switches in
collaboration with physician, while non-pharmacological intervention consisted of diet,
lifestyle and behavior counseling. Outcome measures were glycemic (HbA1c), blood
pressure and lipid controls.
▪ In intra-group comparison, compared to control arm (C, n = 52), subjects in the
intervention arm (I, n = 83) demonstrated significant differences in process outcome
measures; baseline vs final, such as
HbA1c (C; 10.3 ± 1.3 vs 9.7 ± 1.3, p < 0.001, I; 10.9 ± 1.7 vs 7.7 ± 0.9, p < 0.0001),
Systolic blood pressure (SBP) (C; 129.9 ± 13.9 vs 136 ± 7.1, p = 0.0001, I; 145 ± 20.4 vs
123.9 ± 9.9 mmHg, p < 0.0001),
Diastolic blood pressure (DBP) (C; + 4, p = 0.03, I; − 7 mmHg, p < 0.0001), Cholesterol (C;
235.8 ± 57.7 vs 220.9 ± 53.2, p = 0.15, I; 224 ± 55.2 vs 153 ± 25.9 mg/dL, p < 0.0001),
Triglycerides (C; 213.2 ± 86.6 vs 172.4 ± 48.7, p = 0.001, I; 273 ± 119.4 vs
143 ± 31.6 mg/dL, p < 0.0001) and
Estimated glomerular filtration rate (eGFR) (C; 77.5 ± 18.6 vs 76 ± 14.2, p = 0.5, I;
69.4 ± 21.3 vs 93.8 ± 15.2 ml/min/1.73m2, p < 0.0001).
Moreover, both male and female subjects exhibited similar responses towards
intervention with similar improvements in outcome measures.
▪ These data suggested that pharmacist intervention in collaboration with physician in
primary health care settings may result in significant improvements in glycemic, blood
pressure and lipid controls in Pakistani population.
• Lack of updated Knowledge.
• Personnel.
• Training to provide service
• Poor communication skills
• Assumptions that patient care is doctor's responsibility
• Lack of time
• Intra-professional barriers
• Lack of documentation
• Practice setting constraints
BARRIERS TO IMPLEMENTATION OF PHARMACEUTICAL
CARE BY PHARMACISTS IN NSUKKA AND ENUGU
METROPOLIS OF ENUGU STATE
▪ Objective: To identify the possible barriers to the implementation of Pharmaceutical
care among Community and Hospital pharmacists in Enugu State using Nsukka and
Enugu metropolis as a case study.
▪ Method: A semi structured questionnaire was designed to carry out a cross sectional
descriptive study. The questionnaires were distributed to community and hospital
pharmacists from designated areas during one of their quarterly meeting and their
practice sites in 2009.
▪ Results: Eighty completed questionnaires were collected with 22.8% from community
pharmacists, and 77.2% from hospital pharmacists. The important barriers identified
were lack of space, enough personnel in pharmacy to handle routine technical tasks,
time, need for too much effort, and need for payment for services.
▪ Conclusion: The opinions on barriers to Pharmaceutical care of Pharmacists from
community and hospital practice areas in these two metropolises of Enugu State are
majorly 'lack of time, space and routine technical task personnel.
▪ Cameron KA. Preventing medication-related problems among older Americans. Man Care Int
1998;11(10);74-85.
▪ Charles D Hepler,Linda M.Opportunities and responsibilities in pharmaceutical care.American
Journel of Hospital Pharmacy,1990:47:34-43
▪ Satish Kumar,Dr pudota Mariy Pravallika.Need of the Hour-Clinical Pharmacist in Developing
PCP for Better Patient Care.International Journel of Pharmaeutical Sciences Review and
Research.66(2):85-92
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591859/#MOESM1
▪ https://pubmed.ncbi.nlm.nih.gov/24826039/#:~:text=The%20important%20barriers
%20identified%20were,need%20for%20payment%20for%20services.
▪ https://clinicalphar.com/pharmaceuticalcareplan.html
▪ https://www.rxkinetics.com/careplan.html#:~:text=Pharmaceutical%20care%20planning%
20is%20a%20systematic%2C%20comprehensive%20process%20with%20three,patient's%
20potential%20drug%2Drelated%20problems.
