Self care Lecture 2 __________ Patient Assessment & Consultation

1. Self careLecture 2 __________Patient Assessment & Consultation GhadahAsaadAssiri 23/April/2014

2. Outline • Medication therapy management (MTM) • MTM in self care setting • QuEST/SCHOLAR-MAC process • Fever case study • Fever definition , pathophysiology , etiology , complications • S • O • A • P

3. Self care • Medication therapy management (MTM ):is a service or group of services that optimize therapeutic outcomes for individual patients. • 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.

4. Why is MTM is needed? • Medication-related problems and medication mismanagement are a massive public health problem in the United States. • Experts estimate that 1.5 million preventable adverse events occur each year that result in $177 billion in injury and death. APhAMTM Central,2014

5. Goal of Pharmacist Providing MTM • 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. • Indicated • Effective • Safe • Compliance • Economy

6. Self care setting • The patient care process as it pertains to medication therapy management (MTM) includes : • Assessment • Care plan • Follow up & Evaluation • One of the process to evaluate a patient self care needs & drug related need : • QuEST/SCHOLAR-MAC method Self care institute of the AphA

7. QuEST Consultation process • Quickly and accurately assess the patient • Establish that the patient is an appropriate self-care candidate • Suggest appropriate self-care strategies to the patient • Talk with the patient about the selected self-care strategies

8. QuEST/ SCHOLAR Subjective information • Symptoms: what are the main & associated /related symptoms ? • Characteristic :what are the symptoms like? • History : what has been done so far ? Has this ever happened & what was successful ? • Onset : when did this particular problem start? • Location : where is the problem ? • Aggravation factor :what makes it worse ? • Remitting factors : what makes it better ?

9. QuEST/SCHOLAR-MAC Assessment • Medication : prescription , nonprescription and natural product • Allergies : medications and other type of allergies • Conditions :other medical conditions

10. 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 . • 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

11. Fever – Definition • Fever is a common reason for visit to pediatrician offices . • Fever is the leading cause of visits to the ER for children < 15 years • Children have > reported fevers compared to adult • 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 • Hyperthermia : malfunctioning of the normal thermoregulatory process at the hypothalamic level • Hyperpyrexia a body temperature >41.1 C that typically result in mental and physical consequences .May result from pyrogen or hyperthermia

12. Fever- Pathophysiology Hyperpyrexia > 41.1 C

13. Fever – Causes & Complications • Causes • Pyrogens: e.g: bacteria , virus , Drugs : • 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: • Infection is a primary concern • Febrile Seizure (infant, children) • Dehydration , coma, irreversible neurological or muscle damage • Allergy (rash , spots) • Hyperpyrexia :The body temperature >41.1C

14. Fever – Subjective • Elevated temperature • Accompanied with discomfort :Headache , generalized malaise , chills , tachycardia , arthralgia , myalgia , irritability , anorexia.

15. Information Gathering: (1) Symptoms Pt

16. (2) Patient History Information: Pt

17. Fever – Objectives

18. Body Temperature Measurement • Fever should be confirmed only by using a thermometer which is an FDA-regulated medical device. • Core temperature is estimated with various types of thermometer used : • Rectal temperature measurement using electronic thermometer • Oral temperature measurement using electronic thermometer • Digital probe • Digital pacifier thermometer • Axillary temperature measurement using electronic thermometer • Tympanictemperature measurement • Temporal Artery temperature measurement • Factors affecting the type of thermometer : • site of measurement ,age ,availability, preference , convenience

19. Body Temperature Measurement • Do not rely on feeling the body to detect fever .Take a temperature reading with an appropriate thermometer. • 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 • Children < 6 months -infant • Use of a tympanic thermometer is not recommended because of the size and shape of the infants ear canal • Children >6 months –infant : • Rectal method of temperature measurement is preferred. • Children 6 months – 5 years –early childhood : • Rectal method is preferred • Oral, tympanic ,temporal may be used if proper technique is followed • Individual > 5 years –child ,adolescences , adult • Oral , tympanic , temporal method is appropriate

20. Body Temperature Range based on Site of Measurement

21. Assessment Pt

22. Assessment Pt

25. Assessment Pt

26. Assessment- Therapeutic Alternative

27. Assessment- Therapeutic Alternative

29. Acetaminophen Vs Ibuprofen • Efficacy Vs. safety . • Ibuprofen is slightly more effective than acetaminophen, longer duration of action • The Same risk of SE after multiple dosing • Altering different antipyretic for fever reduction has now become a wide spread practice • 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 .

30. Immunization & Antipyretics Vaccine • Prophylactic dose before and immediately after vaccination (controversies ) • widespread practice to reduce discomfort and fever • http://www.pharmacist.com/ask-experts-immunization-and-use-antipyretics

31. 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.

32. Assessment- Alternative • Non pharmacological : • Avoid using isopropyl or ethyl alcohol for body sponging • Alcohol poisoning can result if skin absorption or inhalation • For all levels of fever , wear lightweight clothing , remove blanket & maintain room temperate at ≈20 C. • 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)

33. Plan Pt • Treatment goal : • Relieve the discomfort of fever by returning the body temperature to the normal level • Eliminate the underlying causes. • Prevent complication associated with fever • (6) Select an optimal therapeutic alternative to address the patient's problem, taking into account patient preferences.

34. Plan Pt • (7)Describe the recommended therapeutic approach to the care giver. • (8)Explain to the caregiver the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. • Patient (or parents) should be educated on the proper measurement techniques with the thermometry they utilize • Syringe, dosing spoon , medicine cup (liquid Mx )

35. 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 .

36. Patient education • (9) When recommending self-care with nonprescription medications and/or nondrug therapy, convey accurate information to the caregiver: • 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

37. Follow up Pt. • (10) collect follow-up questions from caregiver. • Pt. : I have ibuprofen liquid at home , is that ok to give in place of the acetaminophen ? • (11) Answer caregiver's questions.

38. Conclusion • Pharmacist require excellent consultation & communication skills in order to be effective in eliciting information from the patient • When prescribing : first line treatment should have proven efficacy • Special consideration apply for children , elderly , pregnant women .

39. Questions ?