Exercise No.

4
Patient Care Pharmacist Care Plan
Date: January 7, 2014
Submitted to:
Reeva Ann Sumulong, MS PHARM, R.Ph.

Submitted by:
Laxamana, Ma. Cristina D.
Section: Pharma 4B
Patient name: FMS
Address: Makati City
Telephone: 531-8502
Insurance: AAS insurance
Medical condition: Osteoarthritis left knee
Tobacco/Alcohol/Substance use: Occassional cigar
3x/week; EtOH 3x/week: no caffeine

Gender: Female
Race: White
Actual Weight: 80kg
Ideal Weight: 75.3kg
Allergies: Penicillin Hives
Adverse reactions: Ibuprofen dyspepsia

Medication Record
Start Date

Stop Date

Indication

Drug Name

Strength

Osteoarthritis

Relafen

750mg

Actual
Regimen
2 tab po QD

HTN

HCTZ

25mg

1 tab po QD

5/17/14

HTN

Triamterene/
HCTZ

37.5/25mg

1 tab po QD

5/31/14

HTN

Atenolol

50mg

1 tab po QD

12/14/12

5/03/13

5/17/13

Clinical
Impression
Tolerating
well; min
knee pain
5/17/13: D/C
due to
hypokalemia
5/13/14: K
WNL; HTN
partially
improved

SOAP
Subjective
Knee pain
Objective
Osteoarthritis left knee
Race: White
Actual Weight: 80kg VS Ideal Weight: 75.3kg (OVERWEIGHT)
Allergies: Penicillin Hives
Assessment
Drug interactions to drug interactions with its medications
Complications with Drugs
Osteoarthritis
Hypertensive
Plan
Health care Need
Drug-drug
interactions with
medications

Pharmacotherapeutic Goal
Eliminate all possible drug-drug
interactions

Recommendation

Monitoring
Parameters

Discontinue use of Nabumetone:

Nabumetone + triamterene
Nabumetone (Relafen) and triamterene both
increase serum K level
(Hyperkalemia)
Nabumetone + Diuretics
Risk of renal pupillary necrosis and other renal
injury

Monitor K serum
level

BUN, Creatinineblood, Creatinineurine, Creatinine

clearance

Complications with
drugs

Eliminate drugs that might

produce complications and
serious injury to the patient

Nabumetone + Atenolol:
Nabumetone decreases the effects of atenolol by
pharmacodynamics antagonism and also both drug
increase serum K
(ineffective anti-HTN drug; Hyperkalemia)
Discontinue use of Triamterene:

Monitor K serum
level

Triamterene and penicillin allergy

Triamterene have been reported to cause acute
transient myopia and acute angle-closure glaucoma
particularly with patients with history of
sulfonamide/ penicillin allergy

Eye examination

Discontinue use of nabumetone:

Osteoarthritis

Hypertension

Date
06/7/14

06/7/14

Alleviate Pain and prevent

prognosis of condition

Normalize patient BP

Medical
Condition
HTN

Osteoarthritis

Drug Therapy
Problem
Ineffective drug
therapy due to drugdrug interactions

Safer drug is needed

because of patient
risk factors
Drug-drug
interactions

Nabumetone and cardiovascular risks

Long term use of nabumetone increases the
possibility of having thrombotic risk event, MI,
stroke which might be fatal; caution on patients
with HTN

Troponins,
Myogloblin

Discontinue nabumetone and prescribe other form

of analgesic which has greater efficacy than its
risks or use of non-pharmacological therapy in
managing pain

Pain: N/A

Monitor Calcium
Levels
Monitor blood
pressure and
electrolytes level
specially serum K
level

Calcium supplementation
Continue Atenolol and HCTZ

Goal
Normalize BP and
eliminate all
possible drug-drug
interactions

Eliminate pain by
pharmacologic or
non-pharmacologic
therapy
Ca
supplementation

Current
Status
Untreated

Tolerating
well; min
knee pain

Interventions
Discontinue: usage of
nabumetone and
triamterene
Continue Atenolol and
HCTZ
To consider other drug
therapy or nonpharmacologic
therapy
Advise patient of
proper diet and
exercise

Follow-up Plan
After 1 week
check BP and
serum K level

After 1 week
assess patient if
condition had
improved and
assess if there are
other concerns
regarding health

B. Questions
1. What is the importance of formulating a complete and efficient pharmacist care plan?
Pharmacy Practice has changed significantly over recent years and continues to evolve toward the provision of pharmaceutical care.
Pharmaceutical care required the effective use of care plans and documentation. "Maintaining adequate records of drug therapy to
facilitate the prevention, identification and management of drug related problems or concerns. These records should contain, but are
not limited to, each patient's current and past drug therapy (including both prescribed and selected over-the counter drugs), drug
allergy history, appropriate demographic data and if known the purpose of therapy and progress toward treatment goals, adverse
reactions to therapy, the patient's history of adherence to treatment, attitudes toward drugs, smoking history, occupational exposure or
risk, and known patterns of alcohol or substance use that may influence his or her response to drugs. Records should also document
patient counseling and advice given, when appropriate."

2. What are examples of drug therapy problems that are needed to be resolved or prevented?
I. INDICATION
Unnecessary Medication
The patient had failed attempts at lifestyle
changes(e.g., exercise, diet, smoking), so a medication
regimen is easier to follow for the patient. As the
patient states, Its just easier to take the pill. It works
great!

Needs Additional Therapy

The patient had a severe hypoglycemic reaction to a
diabetes medication; now she refuses to take another
diabetes medication.

II. EFFECTIVENESS
Needs Synergistic Drug Therapy
The patient feels like she is already treating her
breathing problem. She does not understand why she
should take additional medications to treat the same
condition.

Acknowledge: Agree that it is hard to argue when a medication

successfully does what it is supposed to do.
Help patient to understand that there are other consequences for bad
lifestyle choices.
Find a compromise, encourage small lifestyle changes, which may
eventually lead to an opportunity to stop the medication.
Share safety data related to long-term use of the unnecessary medication,
or potential drug interactions that may apply.
Acknowledge: Agree that it is not acceptable to live with an adverse drug
reaction.
Explain the rationale for treatment.
Share both immediate and long-term benefits of drug therapy.
Give patient the name of the product, let them think about it.
Share willingness to stop therapy if an adverse reaction occurs.
Share that you want to work with the patient, not against her.
Listen to the patients concerns. Share information on how their current
regimen is working, but not producing desired results.
Share how the health condition is often progressive.
Explain how the medications complement each other.
Share how the new medication might enhance the action of the current
regimen, and improve her quality of life.
Share additional health benefits realized when they reach the goal of
therapy or rationale for that goal number.

Dosage Too Low

The patient is reluctant to increase the dose of her
statin. She feels she should be able to do it with
lifestyle changes.

Agree that lifestyle changes are important and offer to work with her on
those changes. Share additional benefits of those changes.
Explain basic pathophysiology on why lifestyle changes may not be as
effective as we would hope.
Involve the patient in shared decision - weigh risks/benefits.

III. SAFETY
Dosage Too High
The patient skips the first dose of the medication and
doubles the second in order to simplify his regimen.

Understand the reasons for feelings of burden and

Validate patients feelings of burden
Learn about the patients daily routine
Share information on the risks associated with doubling the dose
If possible, share once daily medication or simplify regimen.

IV. COMPLIANCE
Patient Forgets to Take Medications
The patient has 4 children, and often cares for her sick
mother. She maintains the household and gets her kids
to various activities. Each day is different, routines,
and mealtimes vary. Medications are not a priority in
patients life.

Help patient to identify things that she does each day at roughly the same
time: brush her teeth, drink coffee, bedtime routines.
State reasons why taking the medication or improving her health will help
her feel better in the short term, become better able to handle stresses
associated with current situations.
Help the patient with some objective measures, home monitoring to allow
her to see the numbers. Either blood pressure monitoring or home glucose
monitoring can help. Give her a short time frame (2-4 weeks) if possible.
Talk about her health goals, let her do the monitoring and realize that the
numbers are above goal.

Patient Prefers Not to Take Medication

The patients copay on her brand name antiplatelet is
expensive. Since she also takes an aspirin each day, she
decided to stop the expensive prescription to save some
money.

Educate about the preventive nature of the medication. Agree that she
may or may not feel any different without the medication. Explain her
increased risk without the medication.
Explain how medication can complement each other to provide even
better outcomes or risk reduction.
Involve the patient in shared decision making to weigh risks and benefits
of the preventive drug therapy.
If cost is a barrier, consider a less-expensive alternative if possible.

3. What are the common causes of drug therapy problems?

Drug therapy problem
Additional drug therapy
required

Unnecessary drug therapy

Ineffective drug therapy

Dosage too low

Adverse drug event

Dosage too high

Drug use problem

Common causes of drug therapy problem

A medical condition requires the initiation of drug therapy.
Preventive drug therapy is required to reduce the risk of developing a new condition (according to the
national guidelines).
A medical condition requires additional pharmacotherapy to produce an additive of synergistic effect.
There is no current valid medical indication for the drug therapy for the individual patient.
Multiple drug products are being used for a medical condition that requires single drug therapy.
The medical condition is more appropriately treated with non-drug therapy or lifestyle changes.
Drug therapy is being taken to treat an avoidable adverse event associated with another medication.
Lifestile ( e.g. drug abuse, alcohol use, diet, smoking) is causing the problem.
The drug is not effective for the medical problem.
The drug product is not the most effective for the indication being treated.
The formulation of the drug products is inappropriate.
The drug is not effective because of the characteristics of the patient. (e.g. renal impairment, hepatic
function)
The dose is too low to produce the desired outcome.
The dosage interval is too long to produce the desired outcome.
A drug-drug interaction reduces the amount of active drug available and the dose is not adjusted too
produce the desired outcome.
The duration of the drug therapy is too short to produce the desired outcome.
The drug causes an undesirable reaction that is not dose-related.
A safer product is required due to risk factors.
A drug interaction, with another drug or food, causes an undesirable reaction that is not dose-related.
The drug is contraindicated due to risk factors or other diseases.
The drug causes an allergic reaction.
A drug dosage was increased or decreased too fast.
A drug alters the patient's laboratory test results due to interference from a drug he/she uses.
The drug causes an undesirable reaction due to too high dose.
The dosing frequency of the drug is too short.
The duration of drug therapy is too long.
The drug dose is too high in the patient because of its characteristics (excretion).
A drug-drug interaction occurs resulting in a toxic reaction to the drug.
The dose of the drug was administered too rapidly.
The patient does not understand the instructions.
The patient prefers not to take the medication.
The patient forgets to take the medication.
The patient cannot administer the drug appropriately him/herself.
The drug therapy does not comply with the lifestyle of the patient.
The patient has no access to the medication.

Reference:
Leendertse et al. BMC Health Services Research 2011 11:4 doi:10.1186/1472-6963-11-4
Shoemaker S., et al. Preventing and Resolving Drug Therapy Problems through Patients Medication Experience: Strategies
employed by MTM Pharmacists. MTM Fairview Pharmacist Services.
http://www.health.state.mn.us/asthma/documents/0511aasummitaphabrochure.pdf
Pharmacy Care Plans. National Association of Pharmacy RegulatoryAuthorities.
http://napra.ca/pages/Practice_Resources/pharmacy_care_plans.aspx?id=2165
Medscape Reference apple app- Nabumetone, HCTZ, Triamterene, Atenolol