Pharmacist-care-manual-surgery.docx

Pharmacist Care Manual Student's Information Student's Name Registration Number Group Number Medical Team

Surgery clerkship

Case Number Setting

Medicine Inpatient Medicine Outpatient

Surgery

Pediatrics

Patient Data Base Demographic and Administrative Information Name (abbreviated) Address Phone # Date of Birth (dd/mm/yy) Age Gender Height (cm) BMI = (Underweight/Normal/Overweight/Obese /Morbid obesity) Admission Date General Health on a Scale of 10 (1 very bad-10 very good) Marital Status Case Summary(chief compliant and what happened to the patient during hospitalization)

History of Present Illness (location, characteristics, aggravating and alleviating factors, timing, severity)

Past Medical History/ Surgery

Family and Social History(diseases in first relatives, caregiver, living arrangement, daily activities)

Life Style(Diet, Exercise, Smoking, Alcohol, Caffeine)

Acute and Chronic Medical Problems (Disease, stage/type/class, current status, duration) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Patient ID MD (consultant) Senior Room No Occupation Weight (kg) IBW Discharge Date Education Level Insurance

Vital Signs / Lab Data ( initial and follow up ) Date

Normal/ Target level (Units)

Vital Signs Wt Temp BP Pulse Resp. Rate RBS

SrCr Cl Cr Urea BUN BUN/ Cr GFR Na K Cl Ca PO4 Troponin CK-MB CPK HbA1c Mg AST ALK ALT Bilirubin total Bilirubin direct Lipase Amylase LDH GGT Albumin Total protein

36.1C-37.2C <140/90 60-100 beat/sec 12-20 bre/min General Biochemistry and hematology < 180 mg/dl 0.7-1.36 mg/dl 75-125 mL/min 15-46 mg/dl 7-20 mg/dl 6:1-20:1 ≥ 60 ml/min/1.73m2

135-152 mmol/L 3.5-5.3 mmol/L 97-110 mmol/L 8.5-10.5 mg/dl 2.7-4.5 mg/dl <0.3 ng/ml Up to 24U/L 25-170 U/L 6.2-8.2 1.6 - 2.4 mEq/L 13-35 U/L 30-122 U/L 10-35 U/L Up to 1.1 mg/dl Up to 0.3 mg/dl 26 – 112 U/L 56 - 194 IU/L 5-39 U/L 3.5-5 g/dl 6.0 to 8.3 gm/dL

Interpretation

Vital Signs / Lab Data ( initial and follow up ) Date RBC Plts Hb Hct WBC Lymphocytes Monocytes Neutrophils Basophils Eosinophils MCV MCH MCHC RDW

Normal/ Target level (Units)

3.8-5.8 140-440 12-16 42±5 4-10 20-45% 2-10% 40-75% 0.5-1% 1-6% 80-100 fL 26-34 pg/cell 31-36 g/dL 11.5-14.5% Arterial blood gases

pH PCO2 PO2 HCO3 TCO2 B.E O2 sat

7.35 - 7.45 35 - 45 70 - 100 22 - 26 21-23 meq/L (-2-+2) 95-100 Urinalysis

Appearance pH Bacteria Glucose Proteins W.B.C/HPF R.B.C/HPF Ep. Cells Others Cholesterol T. G HDL LDL T3 T4 TSH

Yellow Acidic Negative Negative Negative 0-4 WBCs/hpf 0-2 RBCs/hpf <15-20 SEC/hpf < 200 mg/dL < 150 mg/dL > 40 mg/dL < 100 mg/dL 2.63 – 5.69 Pmol/L

9 – 19.1 Pmol/L 0.35 – 5 mU/L

Interpretation

Progress Report and Notes Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

Pre-Meal Target Blood Glucose…………….

Post Meal Target Blood Glucose …………………

Hba1c Target …………….

Blood glucose monitoring sheet Date /day

Pre-breakfast

Post meal

Pre-lunch

Post meal

Pre-dinner

Post meal

Mid night

_ _/_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

As per necessary Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Time _ _:_ _

Action taken

_ _/_ _ Action taken

_ _/_ _ Action taken

_ _/_ _ Action taken

*circle every blood glucose that is out of range and explain what was done to the patient

Patient Data Base Review of Systems

Date General Eyes, ears Nose and throat Cardiovascular Respiratory Gastrointestinal Allergies Genitourinary Musculoskeletal Dermatology Neurology Psychology Endocrine Hematology

Patient Data Base Other diagnostic tests

Date Cardiac Echo

ECG

Cardiac Cath

Chest X-ray

Lung function test

Endoscopy

Others

Patient Data Base PTA Medications Diseases

Drug Name, Generic and brand/Strength/Frequency/ Route

Duration

Effectiveness Patient opinion and Lab Data

Safety Patient opinion and Lab Data/are there any ADR

Patient Data Base Current medications Indication

Drug Name, Generic and brand/Strength/Frequency/ Route

Start-Stop Dates

Time

Effectiveness Patient opinion and Lab Data

Safety Patient opinion, Lab Data, at risk, are there any ADR , Drug interaction?

Anesthesia medication sheet ASA physical class Type of anesthesia

Agent used

…………………… Duration of surgery ……………………….. …..

o o

Length of hospital stay …………………..

Local General

Surgical procedure

Purpose of use

…………………………. Date of surgery ………………

Onset of action

Duration of action

Recommended dose

Dose prescribed

Patient Data Base Discharge Medications Indication

Drug Name, Generic and brand/Strength/Frequency/ Route

Is dose appropriate

Is drug choice appropriate

Duration

Safety Is patient at risk?

Does patient knows special instructions Using Monitoring

Treatment Related Problems Assessment Sheets Type Of Problem

Assessment a) Drug use without an indication b) Addiction or recreational drug use c) The patient treatment should be stepped down (at this stage the patient needs non

1. Unnecessary drug therapy

pharmacological therapy alone or he doesn’t need combination therapy because of improvement in condition or because of guideline recommendations)

d) Duplication (two drugs from the same pharmacological class with no clinical evidence approving such combination)

e) Treating avoidable adverse reaction

2. Untreated condition

a) Untreated conditions that require pharmacological or non-pharmacological therapy

a) More effective drug is available/ recommended

3. Efficacy

b) The patient requires additional/ combination therapy or stepping up because of actual or potential therapy failure or because of guidelines recommendation c) Efficacy dosage regimen issues d) Efficacy interactions issues

4. Safety

a) A current drug is contraindicated/unsafe for patient condition and should be stopped, monitored or replaced b) a safer drug is recommended c) The patient is at high risk for developing ADR and needs monitoring or prophylaxis d) Allergic reaction or an undesirable effects: Are there symptoms or medical problems that may be drug induced? e) Safety dosage regimen issues f) Safety interactions issues

Drugs Involved/Comments

5. Inappropriate knowledge

a) The patient is not instructed or does not understand important information regarding his medications (the purpose of his or her medication(s), how much, how and when to take it, what to avoid, how to prevent side effect and how to monitor his treatment) b) The patient is not instructed or does not understand non-pharmacological therapy or self care advice (avoidance of risk factors, smoking, alcohol, diet, exercise, etc.) a) A problem in patients' adherence to medications (forget, skip, can not afford, Cannot swallow/administer drug etc)

6. Inappropriate adherence

b) Drug product not available c) A problem in patients' adherence to self care activities or non pharmacological therapy

7.Miscellaneous

a) A need for additional or more frequent monitoring b) A need for additional diagnostic test c) A need for consultation d) The chosen medication(s) is not (are not) cost effective e) Other dosage regimen issues f) Other interaction issues g) Patient was discharged too early (i.e. before achieving recommended target) h)Administering errors i) Dispensing errors a) Unnecessary drug therapy b) Untreated condition

8. Treatment related problems on discharge medications

c) Ineffective/incomplete drug therapy d) Actual and potential ADR f) Actual and potential drug interactions g) Inappropriate knowledge h) Inappropriate adherence i) Miscellaneous

  

Assessment section: answer by yes or no Comments section: describe the treatment related problem and the drugs involved Type of intervention section: circle the recommended/ achieved intervention

Consult Note Pharmacist:____________________ Date: _____________________ Patient Name: __________________File Number __________Room__________ DISEASE Subjective Findings ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Objective Findings ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Assessment: (Treatment Related Problems) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Plan Desired Outcomes and Goals_______________________________________________

____________________________________________________________________ Recommendation _______________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Monitoring: Efficacy target____________________________________________________ Toxicity sign ____________________________________________________ Counseling:___________________________________________________________

____________________________________________________________________ Follow up note_________________________________________________________ Reference (see attached): ____________________________________________________________________ Physician/Nurse Decision Agree With Plan Recommended Proposed Modified Plan Disagree ____________________________________________________________________ Physician/Nurse Name: Physician/Nurse Signature:

Consult Note Pharmacist:____________________ Date: _____________________ Patient Name: __________________File Number __________Room__________ DISEASE Subjective Findings: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Objective Findings: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Assessment: (Treatment Related Problems) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Plan: Desired Outcomes and Goals_______________________________________________

____________________________________________________________________ Recommendation _______________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Monitoring: Efficacy target____________________________________________________ Toxicity sign ____________________________________________________ Counseling:___________________________________________________________

____________________________________________________________________ Follow up note_________________________________________________________ Reference (see attached): ____________________________________________________________________ Physician/Nurse Decision Agree With Plan Recommended Proposed Modified Plan Disagree ____________________________________________________________________ Physician/Nurse Name: Physician/Nurse Signature:

Pharmacist Care Plan*

#

Date

Medical Problem or health care need

Physician Action Treatment Related Issue

Recommendations Pharmacotherapy Goals

(Pharmacological, Non-pharmacological, Others)

1

Non-pharmacological

2

Non-pharmacological

* Note: after the initial PCP is written, any new medical or treatment related problem should be indicated in TRP list, PCP, and documented using consult note

Agreed and implemented, Agreed but not implemented, Not agreed

Pharmacist Care Plan Monitoring Sheet/Follow up* Goal #

Monitoring Parameters(subjective, physical, labs, other tests)

Endpoint (Units)

Freq.

Achievement of outcome

1

2

* Use the lab data in patient data base to assess the achievement of outcomes ** Write down lab data and state if the desired outcome was achieved or not (resolved, improved, no change, worsened)

Comments

Pain assessment sheet Date /day

Time

Pain score (0-10)

_ _: _ _

/10

_ _: _ _

/10

_ _: _ _

/10

_ _: _ _

/10

_ _: _ _

/10

Pain management drugs (generic, dose, frequency, route )

Expected Side effects of pain medications

Actual side effects

Precautions

Recommended action *

*recommended action could include: increasing the dose of the current drug, decreasing the dose, adding a new drug to control pain if not controlled Discontinuing drug if intolerable side effects occur, monitoring patient for possible side effects,

Perioperative medication management assessment sheet Medications prescribed

Benefits/ risks

*if the drug to be continued, then use the term "not applicable"

Continue/ discontinue

Time of discontinuation*

When to resume discontinued drug*

Appendix

Treatment Assessment Sheet Presence of kidney or liver impairment (Y/N) Patient's Medical Problems* (with stage or class)

Medications Prescribed**

Presence of special condition (Pregnancy, Geriatric, Pediatric) (Y/N) Treatment of Choice (taking into consideration stage, liver and kidney function, age, pregnancy, other diseases, drugs and individual patient characteristics)

Appropriateness

* Write all the problems that are actually suffered by the patients ** All medication should be included even PRN/STAT/ if not sure about the indication of one of the medications you should check with the patient or the doctor

References (name of publication, year, pages)

Dose Regimen Assessment Sheet Limitations (NPO, Vomiting, Inability to Swallow)

Age

Weight

Degree Of Impairment

BSA (Chemotherapy)

Hepatic

Renal (creatinine clearance)

Recommended Regimen Drug Used

Medical Prob.

(taking into consideration liver and kidney function, age, other diseases, drug interactions and individual patient characteristics)

Str.

Freq.

Route

Durat

Time

Meal

Actual Regimen Str.

Freq.

Route Durat

Time

Agreement

Meal

Dosage Regimen Issues a) Dosage too low

or

b) Dosage too high Given patient factors and condition including age, kidney, and liver functions because of

Dosage regimen issues

- the prescribed dose - frequency - duration - concentration - administration technique - the dose needs stepping up or down according to guidelines recommendations due to a refractory condition or improvement in condition c) The route/dosage form/mode of administration is not appropriate, considering efficacy, safety, convenience, and/or guidelines recommendations d) Timing: doses are not scheduled to maximize therapeutic effect, convenience and and to minimize adverse effects

Drug Interactions Assessment Sheet* Total number of interactions

No. of Category C interactions

No. of category D interactions

No. of category X interactions

Potential interactions Drugs

Risk rating

Severity

Drug 1 ………….. Drug 2 ………….. Drug 1 …………… Drug 2 ………….. Drug 1 ………….. Drug 2 ………….. * Reference used:………………………

Reliability rating

Drug specific or group specific interaction

Effect (discussion)

Patient management

Drug Preparation Assessment sheet Drug

Vial volume

Actual method of preparation Volume Solvent used for Diluent Diluent of the reconstitution used volume solvent

Recommended method of preparation Final conc.

Recommended solvents for reconstitution

Volume of the solvent

Compatible diluents

Diluent volume

Max. recommended

Conc.

Is the preparation appropriate

1.

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

2.

3.

4.

5.

6.

Drug Administration Assessment sheet Drug

Actual method for administration Route of Rate of administration administration

Recommended method for administration Recommended route of Recommended rate of administration administration

Agreement

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

o o

Yes No

Adverse Drug Reaction (ADR) Assessment Sheet Drug 1.

2.

3.

4.

5.

Potential ADR (common or significant)

Risk factors for ADR

Actual ADRs (Check ROS, PE & lab tests)

Patient education sheet Drug prescribed

Proper administration

Dietary instructions

Precautions

‫‪Medications Adherence Assessment Sheet‬‬ ‫استبيان استخدام الدواء‬ ‫* الناس عادة يواجهون مشاكل عدة أثناء تناولهم ألدويتهم الموصوفة لتعددها واختالف أوقاتها وأشكالها‬ ‫واستعماالتها ‪.‬‬ ‫* نود أن نسألك بعض األسئلة عن طبيعة استخدامك لدوائك‬ ‫اطالقا‬ ‫‪1‬‬

‫هل تنسى تناول دوائك؟‬

‫‪2‬‬ ‫‪3‬‬

‫هل تتوقف عن تناول دوائك من وقت آلخر؟‬ ‫هل تتوقف عن تناول دوائك عندما تشعر بتحسن؟‬

‫‪4‬‬

‫هل تتوقف عن تناول دوائك إذا ساءت حالتك بعد أخذ الدواء؟‬

‫‪5‬‬

‫هل تتوقف عن تناول دوائك إذا حصلت لك مضاعفات تعتقد أنها ناتجة عن استخدام‬ ‫الدواء؟‬ ‫هل تلتزم بنصائح الطبيب‪ /‬الصيدالني في ما يتعلق بغذائك‪ ،‬ممارسة الرياضة‪،‬‬ ‫التدخين‪ ،‬الخ‪..‬؟‬ ‫كم مرة أسبوعيا ال تتناول دوائك (تنسى‪ ،‬تتوقف‪ )...‬؟ (يجب أن تكون اإلجابة رقم)‬

‫‪8‬‬

‫ما هي أكثر األسباب التي تعيقك عن أخذ دوائك‪( :‬أجب بنعم أو ال)‬

‫‪6‬‬ ‫‪7‬‬

‫السعر‪,‬‬ ‫الوقت‪,‬‬ ‫النسيان‪,‬‬ ‫ال أحب األدوية‪,‬‬ ‫الدواء ال يعمل‪,‬‬ ‫مضاعفاتها‪,‬‬ ‫كثرة األدوية‬

‫‪.1‬‬

‫نادرا‬

‫أحيانا‬

‫أسباب أخرى؟‬

‫مثال ‪-:‬‬ ‫بعض األشخاص ينسون تناول أدويتهم من وقت آلخر فهل حدث ونسيت تناول أدويتك الموصوفة‪.‬‬ ‫أطالقا ‪ /‬نادرا ً ‪ /‬أحيانا ً ‪ /‬عادة ‪ /‬كثيرا ً ‪.‬‬ ‫أحيانا‪ :‬جرعة في األسبوع ‪.‬‬ ‫عادة‪ :‬جرعتين في األسبوع ‪.‬‬ ‫ًً أكثر من جرعتين في األسبوع‪:‬كثيرا‬

‫عادة‬

‫دائما‬

‫‪Self Care Activities Assessment Sheet‬‬ ‫)‪(Patients with diabetes should answer all questions, others answer 1-6‬‬

‫(يجب أن تكون اإلجابة رقم يتراوح بين ‪)7-0‬‬ ‫‪ .1‬في كم يوم من األيام السبعة السابقة قمت بإتباع حمية غذائية صحية‪.‬‬ ‫‪ .2‬في كم يوم من األيام السبعة السابقة قمت بتناول خمس وجبات أو أكثر من الخضار والفواكه‪.‬‬ ‫( الوجبة تعادل حبة واحدة من الخضار والفواكه)‪.‬‬ ‫‪ .3‬في كم يوم من األيام السبعة السابقة قمت بتناول غذاء يحتوي على كمية عالية من الدهنيات‬ ‫( حليب كامل الدسم ‪ ،‬لحوم حمراء)‪.‬‬ ‫‪ .4‬في كم يوم من األيام السبعة السابقة قمت بممارسة أعمال حركية متواصلة لمدة ال تقل عن‬ ‫‪ 30‬دقيقة‪.‬‬ ‫‪ .5‬في كم يوم من األيام السبعة السابقة قمت بممارسة أنواع خاصة من الرياضة (السباحة ‪،‬‬ ‫الركض‪ ،‬المشي) غير الذي تقوم به يوميا في بيتك أو عملك‪.‬‬ ‫‪ .6‬كم عدد السجائر التي تقوم بتدخينها يوميا‪.‬‬ ‫‪ .7‬في كم يوم من األيام السبعة السابقة قمت بقياس تركيز السكر في دمك ‪.‬‬ ‫‪ . 8‬في كم يوم من األيام السبعة السابقة قمت بفحص قدميك‪.‬‬ ‫‪ . 9‬في كم يوم من األيام السبعة السابقة قمت بفحص حذاءك‪.‬‬

‫*‪Patient Education Sheet‬‬ ‫‪Discharge Medications and Chronic Diseases‬‬

‫األدوية‬ ‫االسم‬ ‫العلمي‬

‫الجرعة‬ ‫(حبة مرتين يوميا بعد‬ ‫األكل)‬ ‫االسم‬ ‫التجاري‬

‫أي تعليمات خاصة‬ ‫(مراقبة مضاعفات‬ ‫الدواء‪ ،‬مراقبة فاعلية‬ ‫الدواء‪ ،‬تخزين الدواء‪،‬‬ ‫منع مضاعفات الدواء)هذا‬

‫لماذا تأخذ‬ ‫الدواء‬

‫األمور أو العوامل التي‬ ‫يجب تجنبها بالنسبة‬ ‫للمرض‬

‫طبيعة الطعام التي‬ ‫يجب تجنبه أو تناوله‬ ‫بالنسبة للمرض‬

‫أمور أخرى‬ ‫بالنسبة للمرض‬

‫)‪* Complete the charts with the patient using patient own words (Arabic‬‬ ‫‪* Identify the gaps in patient knowledge and then fill in the gaps‬‬ ‫‪* Give a copy to the patient‬‬