Principles of Clinical Pharmacy

1. what is clinical pharmacy: the branch of pharmacy in which pharmacists provide patient care that optimizes the use of medication and promotes health, wellness, and disease prevention 2. what does SAE mean: safety, appropriateness, efficacy 3. what is the job role of clinical pharmacists: to improve the quality of prescribing by influencing prescribers or directly prescribing themselves 4. how is good quality prescribing measured: good quality prescribing is when the patients wants, technical properties of the dug and general good overlap 5. what are the four principles of medical ethics that are relevant in the clinical pharmacy process: - beneficence (doing good) - non-maleficence (not doing harm) - justice (the greater good) - patient autonomy (choice) 6. what aspects of the prescribing, administration, use of medicines can pharmacists positively influence: - the need for a drug - selecting appropriate drug - select regimen - provide drugs (dispensing, supply, time keeping) - drug administration - monitoring drug therapy - counsel effectiveness 7. what does select regimen mean: when the dose, frequency of the drug is the most effective as the lowest cost 8. what skills and attitudes does a clinical pharmacists need: - clinical; interpreting medical notes, lab data - communication - medicines optimisation - professionalism and ethics - diagnosis, clinical reasoning and prescribing - evidence based medicine and critical appraisal - CPD 9. what theoretic knowledge does a clinical pharmacists need: - therapeutics - pharmacology - pharmaceutics - pharmaceutical chemistry - pharmacokinetics 10. what is the format (order) of medical notes: 1. details of administration 2. lab results 3. correspondence 1 / 11 4. TTOs/drug charts 5. nursing notes 11. what is the format (order) of medical notes: DETAILS OF ADMINISTRATION: - record of every admission to hospital patient has had - clerking sheet - if patients admitted progress notes are added to record details of follow up consultations until patients discharged 12. what is a clerking sheet: first point of info gathering about a patient's condition before hospital admission - results in provisional diagnosis and management plan 13. what is the format (order) of medical notes: LAB RESULTS: - haematology results (blood tests) - microbiology results - lung function tests - scans - ECGs - echocardiograms (scan to look at heart and nearby blood vessels) 14. what is the format (order) of medical notes: CORRESPONDENCE: - health care professionals communicating with each other - letters exchanged between primary care (GPs, CCGs, community pharms), secondary care (hospitals), tertiary care (specialist hospitals) 15. what is the format (order) of medical notes: TTOs/DRUG CHARTS: - drug charts from current/previous admissions and copies of out-patient and take home medications 16. what is the format (order) of medical notes: NURSING NOTES: these include - bedside monitoring: BP, temp, pulse, respiratory rate - how patient is feeling - patient eating and drinking - patient bowel movements - if patient has taken meds 17. what is included in the admission process: - personal details - PC (presenting concerns) - HPC (history of presenting complaint (story about concern)) - PMH ( previous medical history) - SH (social history) - FH (family history) - DH (drug history) - ROS (review of systems) - results: blood tests, microbiology reports, radiographic/radiology tests 2 / 11 - problem - diagnosis and plan 18. what is social history: - family support - foreign travel - interests - smoking status - alcohol intake 19. what is included in the review of body systems: 1. general examinations 2. cardiovascular system 3. respiratory system 4. gastrointestinal system 5. genitourinary system 6. neurological system 7. musculoskeletal system 8. endocrine system 20. review of body systems: general examination: - consciousness using GCS (glasgow coma scale) - level of pain - patient mood - patient weight - personal care - general observations (vitals) - if patient is dehydrated or oedematous 21. review of body systems: cardiovascular systems: - jugular venous pressure (JVP) measurements of right atrial pressure - electrocardiogram (ECG) -heart rate - blood pressure - heart sounds - heart murmurs - peripheral pulses - oedema - capillary refill time - chest pain - shortness of breath - orthopnoea: when you find it harder to breathe when you lie down because of fluid in the lungs - claudication: pain in legs/arms while walking or using arms 3 / 11 - paroxysmal nocturnal dyspnoea (PND): shortness of breath that awakens patient - cubbing: changes in areas under/around toenails & fingernails 22. review of body systems: respiratory systems: - diagrams used: arrow through diagram =clear lungs. crosses or musical notes indicate sounds were heard and their location relate to the location the sounds were heard observations: - it patient has cough - quantity/appearance of sputum produced - presence of haemoptysis (coughing up blood) - shortness of breath - respiratory rate - oxygen saturations 23. review of body systems: gastrointestinal system: - diagram of abdomen used to indicate: - scars present - masses felt - organomegaly (enlargement of an organ) - any bowel sounds - abdominal distention - tenderness - guarding (Ab muscles sense to protect inflamed organ within abdomen) 24. what are some of the other GI observation: checks to see whether patient has - dysphagia (swallowing difficulties) - heartburn - changes in appetite - weight change - nausea - vomiting - abdominal pain - mouth ulcers - jaundice - rectal bleeding - changes in stool frequency/ colour/smell (bristol stool chart) 25. review of body systems: genitourinary system: symptoms looked for: - dysuria (painful urination) - nocturia (waking up to urinate) - changing in frequency to urinate - haematuria (blood in urine) - testicular pain/smelling 4 / 11 - erectile problems - changes in libido - pregnancies - dysmenorrhea (painful cramps) - menorrhagia (heavy periods) also inspected for: - lumps, ulcerations, rashes, swelling, haemorrhoids, discharge 26. review of body systems: neurological system: observations: - faints, fits, loss of consciousness - headache changes/problems with: - eyesight, hearing, sense of smell, speech, dysphasia, gait, mobility, coordination - dizziness - weakness/lethargy - numbness/tingling - alertness - muscle strength and function - reflexes - mini mental state exam - vertigo - confusional state - stammer - tremor - memory tissues - concentration issues - ocular problems (eyes) 27. review of body systems: musculoskeletal system (bones, cartilage, tendons, ligaments, joints: if patient has: - pain/tenderness - swelling - stiffness - heat - limits to movement of activities - gait (persons pattern of walking) - muscle wasting - deformities 28. review of body systems: endocrine system: if patient has: - irritability - polydipsia (excessive thirst) 5 / 11 - polyuria (urinating more than usual) - sweating - skin/hair dryness - acne 29. what is included in the admission process: problem, diagnosis and plan: doctor indicates likely diagnosis termed 'impression' or differential diagnosis: where more than one possible diagnosis is needed - triangle in notes indicates 'diagnosis' or 'differential diagnosis' - plan: initial management planned: further tests, treatment, referrals or discharge 30. what are reference ranges (lab data): reference ranges for each lab data parameter given as a guide of 95% of the healthy population 31. why is lab data important: is useful in the diagnosis, screening, monitoring of patients 32. can lab data be used alone to indicate disease: no - data must be interpreted alongside patients signs and symptoms 33. what does deranged mean (lab data): - when the value for a particular parameter is outside reference range 34. what are the causes of deranged values (lab data): - disease patient has - meds patient is taking/changes/stopped - change in patients diet or fluid intake 35. what are erroneous results: - incorrect reading due to incorrect lab techniques 36. why are blood tests used: check for - urea and electrolytes - liver functions - blood cell counts 37. urea and electrolytes are used to assess fluid and electrolyte balance. what does this include: - sodium - potassium - calcium - phosphate - urea - creatinine 38. deranged electrolyte levels: HYPOnatraemia: low sodium causes: - water retention - loss via sweating, vomiting, diarrhoea signs/symptoms: - headache 6 / 11 - nausea - drowsiness - confusion 39. deranged electrolyte levels: HYPERnatraemia: too much sodium causes: - dehydration - increased sodium in diet signs/symptoms: - muscle weakness - confusion - thirst 40. deranged electrolyte levels: HYPOkalaemia: low potassium causes: - loss from GI tract - overhydration - diuretic drugs signs/symptoms: - muscle weakness - confusion - hypotonias - arrhythmias 41. deranged electrolyte levels: HYPERkalaemia: high potassium causes: increased K in diet or supplements - reduced elimination in conditions - ACE inhibitors signs/symptoms: - tachycardia - sudden death 42. deranged electrolyte levels: HYPOcalcaemia: low calcium causes: - reduced albumin - hypoparathyroidism signs/symptoms: - tetany - depression 7 / 11 43. deranged electrolyte levels: HYPERcalcaemia: high calcium causes: - hyperparathyroidism - malignancy signs/symptoms: - abdominal pain - vomiting - constipation - polyuria - confusion 44. deranged electrolyte levels: HYPOphosphataemia: low phosphate causes: - excess use of antacids as they bind with dietary phosphate signs/symptoms: asymptomatic if mild severe: - weakness - bone pain - rhabdomyolysis 45. deranged electrolyte levels: HYPERphosphataemia: high phosphate causes: - chronic renal failure - hypoparathyroidism signs/symptoms: - fatigue - shortness of breath - anorexia - nausea and vomiting - sleep disturbances 46. deranged electrolyte levels: HYPOmagnesaemia: low magnesium causes: - diarrhoea - ketoacidosis - alcohol signs/symptoms: - fits 8 / 11 - tetany - arrhythmias 47. deranged electrolyte levels: HYPERmagnesemia: high magnesium causes: - excessive antacids signs/symptoms: - hypotension - CNS depression 48. what is low and high urea caused by: - lack of protein (low) - dehydration or bleeding (high) 49. what are urea and creatinine markers of: markers of renal function - high levels of both indicate renal impairment 50. what does clearance of creatinine mean: - creatinine = product of muscle breakdown and excreted by kidney - therefore clearance rate good indicated good kidney function 51. creatinine clearance or glomerular filtration rate: Cockcroft and gault equation: - CrCl (mL/min) = N x [140-age (years)] x weight* (kg) divided by Serum creatinine (micromol/L) - Where N = 1.23 males, 1.04 females - * Use ideal body weight (IBW) if actual weight is greater than 120% IBW 52. what are the two main functions of the liver: - protein production - metabolism 53. explain albumin and bilirubin in terms liver impairment: - liver makes albumin, when liver fails, it wont make albumin therefore low levels of albumin indicates impaired liver function - bilirubin = product of breakdown of haemoglobin and bins to albumin, if albumin is low, less bilirubin can bind therefore bilirubin increases - low albumin and high bilirubin indicates liver impairment 54. explain the splits of white blood cells: - WBC - granulocytes: neutrophils, eosinophils, basophils - agranulocytes: monocytes, lymphocytes 55. explain what happens in order for white blood cells to be raised: - neutrophils: infection and tissue necrosis - basophils: chronic hypersensitivity reactions - eosinophils: parasitic infection and allergic reaction 9 / 11 - monocytes: infection - lymphocytes: viral infections 56. what can cause low RBC count: - blood loss - anaemia = deficiency of RBC 57. explain where platelets are formed and the cause of a low platelet count: formed in bone marrow and initiate haemostasis - thrombocytopenia (low platelets): caused by drugs, lymphoma and idiopathic thrombocytopenia purpura (ITP) 58. what is erythrocyte sedimentation rate (ESR) and C reactive protein (CRP): - ESR: rate at which blood cells settle out of venous blood - ESR and CRP levels increase when there is inflammation in the body 59. what is bedside data: - blood pressure - heart rate: irregularities caused by arrhythmias - temperature: infection usual cause - respiratory rate - oxygen saturations - glucose 60. what is bedside data: blood pressure: - hypotension: low bp = causes dizziness, fainting, poor blood circulation - hypertension = no symptoms - hypertension can only be diagnosed if repeated reading are high and the readings must be taken across several days and at different times to ensure that Bp is consistently high 61. what is bedside data: respiratory rate: - low rate = dizziness, fatigue, confusion - high rate cause = exercise, pregnancy, carbon monoxide poisoning - presents as breathing difficulties 62. what is bedside data: oxygen saturations: - extent to which haemoglobin is carrying oxygen - low saturation seen in people with chronic respiratory condition, acute MI and sepsis - pulse oximetry used to test a patient's oxygen saturations 63. what is bedside data: glucose: - blood glucose (BG), capillary blood glucose CBG - finger prick then adding blood to a meter - hyperglycaemia = high BG can indicate diabetes - hypoglycaemia = low BG caused by fasting, too much insulin symptoms, sweating, dizziness, fatigue, blurred vision, shaking, confusion 10 / 11 - glycosylated haemoglobin formed when elevated levels of glucose bind irreversible to haemoglobin. indicates long-term glucose control 11 / 11