tpn pwdt form.pdf

PHARMACIST WORKUP OF

DRUG THERAPY IN

PHARMACEUTICAL CARE

Date: 12/12/13

Department: Parenteral Nutrition

Case : Parenteral Nutrition (PN) for Post Laparotomy of Subacute

Intestinal Obstruction

Ward: 3A

Reg. No: 1229888

Name of Students: TAZQIRAH BT MUHAMAD (2010285624)

ZARITH NADIA BINTI MOHAMAD ZULKIFLI (2010663642)

PROBLEM ORIENTED

PHARMACIST RECORD Department of Pharmacy Practice

Faculty of Pharmacy

Universiti Teknologi MARA

CASE 1

A. Patient Description

Name : CNL Age : 77

Reg. No : 1229888 Gender : Male [ ] Female [ / ]

Admission : 19/12/11 Weight : 49.7 kg

Race : Malay [ ] Chinese [ / ] Indian [ ] Height : 150 cm

B. Chief Complaint (CC)

Patient was admitted to Ward 3A, Hospital Tengku Ampuan Rahimah (HTAR) Klang on

19/12/11 due to abdominal pain for 1 day with nausea and vomiting for 5 times.

C. History of present illness (HPI)

Patient was diagnosed with hypertension for more than 30 years ago. She had undergone

cholecystectomy 10 years ago.

D. Family & Social History

She is taken care by her daughter. She was an ex-smoker.

E. Medical History Interview

HEART PROBLEMS: URINARY/REPRODUCTIVE:

Chest pain (angina) Urinary or bladder infection

Past heart attack Prostate problems

Heart failure Hysterectomy

Irregular heartbeat Chronic yeast infections

Heart by-pass surgery Kidney disease

Rheumatic fever Dialysis

Other: Other:

EYES, EARS, NOSE & THROAT MUSCLES AND BONES

Poor vision Arthritis

Poor hearing Gout

Glaucoma Back pain

Sinus problem Amputation

Bladder disorder Joint replacement

Other: Other:

GASTROINTESTINAL NEUROLOGICAL

Heartburn Headache

Ulcer Seizures or epilepsy

Constipation Parkinson’s disease

Diverticulitis Dizziness

Liver disease Past stroke

Gallbladder problems / Fainting

Pancreatitis Depression

Other: Anxiety

Other:

DO YOU HAVE: LUNG PROBLEMS

High blood pressure / Asthma

Low blood pressure Emphysema

High cholesterol Bronchitis

Diabetes Other:

Cancer

Anaemia

Bleeding disorder DO YOU HAVE OR USE…?

Hay fever Glasses

Sleeping problems Hearing aid

Other: Other:

DO YOU HAVE A FAMILY HISTORY OF:

High blood pressure

Heart disease Other:

Diabetes

F. Medication history

F.S.1 Current Prescription Medication Regimen

Name/Dose/

Strength/Route

Schedule/

Frequency

of Use

Indication Start Date

(and stop

date if

applicable)

Prescriber Indication

issues,

effectiveness,

safety,

compliance

and cost

Tab. Losartan

potassium/hydro

chlorothiazide

100/25 mg

OD Anti-hypertensive

agent

Tablet

Amlodipine

besylate 5mg

OD Anti-hypertensive

agent

F.S.2 Current Nonprescription Medication Regimen (OTC, herbal, homeopathic,

nutritional, etc.)

Name/Dose/

Strength/Route

Schedule/

Frequency

of Use

Indication Start Date

(and stop

date if

applicable)

Prescriber Indication

issues,

effectiveness,

safety,

compliance

and cost

G. Allergies:

History of allergies: Yes [ ] No known allergies [/ ]

Are you allergic to any prescription drugs, over-the-counter medication, herbals or food

supplements?

Yes No. If yes, please list the medications and type of

allergic reaction experienced:

Are there any medications that you are not allergic but cannot tolerate?

[ ] Yes [ / ] No If yes, please list the medications and the reaction experienced:

What environmental allergies do you have? Nil

H. Medication Compliance assessment

Base questions on history obtained to this point.

Your medication regimen sounds complex and must be hard to follow;

How often would you estimate that you miss a dose?

Never___________________________________________________________________

Everyone has problems with following a medication regimen exactly as written.

What are the problems you are having with your regimen?

No problem______________________________________________________________

Compliance rate: Compliant [ / ] Moderate/partial compliant [ ] Noncompliant [ ]

I. Social History

Smoking:

Do you use tobacco?

/

/ Yes No If yes, what type? Packs/day ________ years.

If no, Never consume [ ], stopped [ ] 30 year(s) ago.

Alcohol :

Do you drink alcohol? Chronic alcoholic

Yes / No If yes, what type? Drinks/day/week.

If no, Never consume [ ] , stopped [ ] year(s) ago.

Other Drug use:

Caffeine intake: Never consumed [ / ] drinks per day , Stopped __ year(s) ago.

Drug/substance abused: Never consumed [ / ] , If yes What type

_________________

Diet Routine Exercise/Recreation Daily Activities/Timing

- - -

J. Risk Assessment/Preventive Measures/Quality of Life

Please calculate the 10-year Coronary heart disease (CHD) risk in this patient

according to the Modified Framingham Risk Scores For Men and Women (appendix:

Table 2)

Modified Framingham Risk Scores for Men and Women

Male Female

Point total 10 year risk (%) Point total 10 year risk (%)

0 1 <9 <1

1 1 9 1

2 1 10 1

3 1 11 1

4 1 12 1

5 2 13 2

6 2 14 2

7 3 15 3

8 4 16 4

9 5 17 5

10 6 18 6

11 8 19 8

12 10 20 11

13 12 21 14

14 16 22 17

15 20 23 22

16 25 24 27

>17 >30 >25 >30

J. Physical examination / laboratory for initial and follow-up.

Lab investigation

Date 19/12 Date 19/12

Height(cm) 150 Na+ 139

Weight(kg) 49.7 K+ 3.4

Temp(C°) 37 BUN 15.5

Bp(mmHg) 142/82 Creatinine 259

Pulse(bpm) 88 Urine output -

RR/VENT 13 I/O -

Peak Flow - Uric acid/Mg 0.64

PH - Ca2 1.86

Osat - PO4 1.11

PCO2 - FBS/RBS -

HCO - BMI 22.09

LDL - LDH -

HDL - CPK -

TG - INR -

T.Choles. - PT/aPTT -

WBC 4.06 TT/FDP -

Hgb 13.1 BLI Bili -

Platelet - ALT/AST -

Chest X-ray - Alk Phos -

Echocardio - Total P/Alb -

ECG - TSH -

- CrCl(ml/min) 12.57

Pharmacologic review of system:

General: Alert, conscoius, colicky abdominal pain, nausea,

vomiting_______________________________________________

Vital Signs: BP: 142/82 mmHg, PR: 88 beats/min, RR: 13 beats/min,

T: 37°C ___________________________________ ___________

KUT: _____ _______

HEPATIC: _____________________________________ ______

CVS: __________ ____ __________

CHEST: _____________________ ________________________

BLOOD: _____________________________________ ________

ABDO: _______________________________________________

SKIN/MUSCLE: _______________________________________

NEURO/MENTAL: _____________________________________

HEENT: _____________________________________ ________

GIT: ________________________________________ _________

9

Vital Signs

19/12 21/12 23/12 25/12 27/12 28/12

T (oC) 37 37 36.6 37 37 37

BP (mmHg) 142/82 137/53 150/65 120/75 140/80 142/58

HR (beat/min) 88 75 80 93 66 -

I/O: Input/Output - 2082.5/3510 2672.5/4360 3083/3105 2647.5/2183 3100/1637

Balance - -1427.5 -1687.5 -22 464.5 1463

Renal Profile

Normal range 21/12 23/12 25/12 27/12 28/12

Na+ 135 – 145 mmol/L 139 135 136 138 140

K+ 3.5 – 5.0 mmol/L 3.1 ↓ 3.5 4.5 4.3 4.2

Urea 1.7 – 8.3 mmol/L 16.2 ↑ 22.9 ↑ 28.4 ↑ 31.8 ↑ 21.0 ↑

Creat 57-130 μmol/L 232 ↑ 245 ↑ 195 ↑ 101 63

Clcr 75 – 125 ml/min 14.0 13.2 16.6 32.2 51.69

PO4- 0.81-1.45 mmol/L 1.4

1.45 1.34 1.39 1.16

Mg 0.66-1.30 mmol/L 0.65 1.3 1.01 1.22 1.16

↓: Lower than normal range

↑: Higher than normal range

10

Evaluation of renal function

(Please choose at what stage of renal impairment that the patient is having based on your

calculated creatinine clearance. Formula is given at the appendix)

Estimated GFR using MDRD equation

= 186 x (SCr / 88.4)-1.154

x (age)-0.203

x (0.742 if female) x (1.210 if black)

= 186 x (259 / 88.4)-1.154

x (77)-0.203

x (0.742)

= 16.53 ml/min/1.73m²

Stage Description GFR ml/min/1.73m2 Patient’s CKD stage

1 Kidney damage with normal or ↑GFR ≥90

2 Kidney damage with mild ↓GFR 60 – 89

3 Moderate ↓GFR 30 – 59

4 Severe ↓GFR 15 – 29 16.53 ml/min/1..173 m2

5 Kidney failure (ESRD) <15 (or dialysis)

Cardiac Enzymes

Normal range

CK 30 - 200 -

LDH 135 - 225 -

Aspartate Transaminase 5-34 -

Others

Normal range 21/12 23/12 25/12 27/12 28/12

RBS 4-11mmol/L 6.2 7.4 6.9 9.7 6.7

K .Diagnoses/Provisional Dx / Acute / Chronic medical Problems

- Subacute intestinal obstruction obstruction 2° to adhesion colic

- Hypertension (>30 years ago)

- Cholecystectomy (>10years ago)

11

L. Drug treatment in the ward

Current Drug Therapy (Oral, Parental, Inhaler and others)

Drug Name Prescribed

Schedule

Duration Indication

Start Stop

IV Tienam (imipenem +

cilastatin) 500mg

TDS 20/12/11 21/12/11 Surgical prophylaxis

-broad spectrum bactericidal agent

IV Fluconazole 200mg OD 21/12/11 27/12/11 Treatment of fungal infection

IV Tazocin (Piperacilin +

Tazobactam) 4.5g

OD 21/12/11 23/12/11 First line of intra-abdominal sepsis

IV Meropenem 1g TDS 24/12/11 29/12/11 Intra-abdominal infection

T. Metoprolol 50mg BD 21/12/11 26/12/11 Hypertension

T. Metoprolol 100mg BD 26/12/11 Continue Hypertension

S/C Enoxaparin Sodium

40mg

OD 20/12/11 28/12/11 Prophylaxis of deep vein

thrombosis

T. Amlodipine 5mg STAT & OD 19/12/11 Continue Hypertension

T. Simvastatin 40mg ON 19/12/11 Continue Prevention of cardiovascular events

IV Frusemide 40mg Run 1mg/hour 21/12/11 Continue Treatment of resistant hypertension

and prevention of fluid overload

Mist KCl 15ml TDS 21/12/11 29/12/11 Treatment of potassium deficiency

IV KCl 1g STAT 21/12/11 Continue Treatment of potassium deficiency

IV Ranitidine 50mg TDS 19/12/11 20/12/11 Prophylaxis of stress ulcer

IV Filgastrim 300mcg/ml

[recombination human

granulocyte-colony

stimulating factor (G-

CSF)]

OD 21/12/11 Continue Treatment of anemia (off label

used) and neutropenia

IV Bromhexine 8mg TDS 22/12/11 24/12/11 Mucolytic agent

IV Tramadol 25mg BD 22/12/11 Continue Relief of moderate to severe pain

IV Pantoprazole 40mg BD 21/12/11 26/12/11 Proton pump inhibitor

Prophylaxis of stress ulcer

T. Folate/ B complex

40mg

OD 28/12/11 Continue To provide energy

Treat anemia

T. Esomeprazole 40mg OD 27/12/11 Continue Proton pump inhibitor

Prophylaxis of stress ulcer

IV Vit K 10mg STAT 22/12/11 Continue Correct any clotting defect

IV N-Acetyl Cysteine 25/12/11 26/12/11 Mucolytic agent

12

Patient’s progress report in the ward

Date 19/12 20/12 21/12

General

Alert, conscious, lethargic looking,

mildly dehydrated, pink (not

jaundiced)

General condition same, a febrile,

calcified uterine fibroid noted

General condition same,

Gangrenous bowel 2° to internal

herniation

Vital signs

BP 142/82 139/67 137/53

PR 88 103 75

RR - 13 17

T 37 37 37

CVP - - -

O2Sat - - -

Lungs - - -

Abdomen Colicky abdominal pain Colicky abdominal pain No pain

CVS - - -

DXT (mmol/L) - - 6.2

Plan

- Start T. Amlodipine 5mg

stat & od

- Start T. Simvastatin 40mg

on

- Start IV Ranitidine 50mg tds

- Monitor BP 2 hourly

- KIV to add another

antihypertensive if

persistently high

- Keep patient NBM

- Start IV drip 4pins (normal

saline and dextrose 5%)

- Off IV Ranitidine 50mg tds

- Start T. Pantoprazole 40mg

bd

- Monitor vital signs

- Inform stat if bp> 100/90

mmHg or PR > 120

beats/min

- Start IV Imipenem 500mg

tds

- Start S/C. Enoxaparin

Sodium 40mg od

- Laparotomy on 10.30 p.m.

- Off IV Imipenem 500mg tds

- Start IV Fluconazole 200mg

od

- Start IV Piperacilin 4.5g od

- Start T. Metoprolol 50mg bd

- Start IV Frusemide 40mg run

1mg/hour

- Start IV KCl lg stat then

convert to Mist. KCl 15ml tds

- Start IV Filgastrim

300mcg/ml

- Start TPN

13


Date 22/12 23/12 24/12

General


decompensated metabolic

acidosis


respiratory distress

General condition same, pupil

sluggish bilaterally, poor GCS

Vital signs

BP 150/55 150/65 135/70

PR 68 80 102

RR 23 13 18

T 37 36.6 37

CVP - - -

O2Sat - - -

Lungs - - -

Abdomen

No pain No pain No pain

CVS - - -

DXT (mmol/L) 6.4 7.4 7.4

Plan

- Start IV Tramadol 25mg

bd

- Start IV Vit K 10mg stat

to correct any clotting

defect

- Off IV Piperacilin 4.5 g

od

- Start IV Meropenem 1g

tds

- Off IV Bromhexine

14


Date 25/12 26/12 27/12

General

General condition same, sepsis General condition same Alert, not tachypnea, GCS

improved

Vital signs

BP 120/75 143/83 140/80

PR 93 101 66

RR 14 20 22

T 37 37 37

CVP - - -

O2Sat - - -

Lungs - - -

Abdomen No pain No pain No pain

CVS - - -

DXT (mmol/L) 6.9 9.9 9.7

Plan

- Start IV N-Acetyl

Cysteine

- Continue IV Fluconazole 200mg tds

- Continue IV Meropenem

1g tds

- Continue T. Metoprolol 50mg bd

- Continue S/C Enoxaparin

Sodium 40mg od - Continue Mist KCl 15ml

tds

- Continue IV Pantoprazole 40mg bd

- Off T. Metoprolol 50mg

bd, then convert to T.

Metoprolol 100mg bd

- Off IV Pantoprazole

40mg bd

- Off IV N-Acetyl Cysteine

- Off IV Fluconazole 200mg

od

- Continue IV Meropenem

1g tds

- Continue T. Metoprolol

100mg bd

- Continue S/C Enoxaparin

Sodium 40mg od

- Start IV Esomeprazole

40mg od

- Off TPN, allow oral

feeding

15

N. DRUG THERAPY PROBLEM LIST (DTPL)

Date DRP (medication related) Recommendation

20/12/11 Uncorrected hypoalbuminemia (low serum albumin)

which can be caused by malnutrition, impaired

digestion and edema.

Serum albumin level is an important prognostic

indicator. Among hospitalized patients, lower serum

albumin levels correlate with an increased risk of

morbidity and mortality. Therefore, treatment should

focus on treating the underlying cause of

hypoalbuminemia first before giving IV Human

Albumin 5% to the patient.

21/12/11 Patient had anemia due to surgery and was prescribed

with IV Filgastrim 300 mcg to correct patient’s anemic

status.

Filgastrim is indicated more on treating neutropenia

rather than anemia (off label use). Thus, it is

recommended to transfuse 1 unit packed cell to

correct patient’s blood count because she cannot

tolerate oral feeding yet.

21/12/11 Potassium level was below than normal range. Suggest to give IV potassium chloride, KCl 1g stat to

correct patient’s hypokalemic status.

21/12/11 Patient was started on antifungal IV Fluconazole

200mg od. However, there was no fungal infection has

been reported and antifungal prophylaxis was not

indicated for the patient.

Recommend to stop antifungal therapy for the patient

in order to prevent any use of unindicated medications

in patient.

19/12/11 Incorrect dose of tab. Simvastatin 40mg when

prescribed with tab. Amlodipine.

The U.S. Food and Drug Administration (FDA)

recommended limiting the use of simvastatin with

certain drugs due to increased risk of

myopathy/rhabdomyolysis. The maximum

recommended dose for simvastatin in conjunction

with amlodipine is 20 mg per day.

16

28/12/11 Untreated anemia even though IV filgastrim has been

prescribed to the patient.

Suggest to give ferrous fumarate, folic acid and

hematinic since the patient can already tolerate enteral

feeding.

26/12/11 DXT showed high dextrose level on 26/12/11 and

27/12/11.

High dextrose level can lead to hyperglycemia which

is one the metabolic complication of TPN. Thus, it is

recommended to monitor dextrose level closely and

suggested for intensive insulin therapy if necessary.

21/12/11 -

27/12/11

TPN bag 5 (total energy: 1000 kcal) has been selected

on the first day while for the rest 6 days of total

duration, TPN bag 6 (total energy: 1400 kcal) was

given to the patient.

Based on customized calculation, total energy required

for the patient is 1445 kcal.

Based on the guideline, it is recommended to start and

stop TPN slowly to prevent re-feeding symptom and

to meet total nutrition required for the patient.

17

O. PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PMW)

Pharmacotherapeutic

Goal (based on the above

DRP)

Monitoring

Parameter

Desired

Endpoint

Monitoring

Frequency

1. Treat the underlying

cause that lead to

hypoalbuminemia.

Serum albumin

level

To correct hypoalbuminemia before

albumin replacement can be done

Every day

2. Treat anemia.

i)RBC count

ii) Hemoglobin

count

iii) Hematocrit

count

4.5 – 5.5 10 12 /µL

13 – 17 g/dL

40 – 50 %

Every day

3. Control the blood

glucose level.

i) Random blood

glucose level

ii) Fasting blood

glucose level

< 10 mmol/L

< 7 mmol/L

Upon admission

Every 2 days

4. Maintain the blood

pressure within desired

range.

Blood pressure < 120/80 mmHg Every 6 hours

5. Monitor patient’s

condition closely to ensure

that TPN given provides

adequate amount of fluid,

nutrients, etc.

Patient’s hydration

status, serum

electrolytes level,

blood glucose,

other nutrients

To ensure the patient received adequate

amount of nutrients and fluid needed

from TPN bag given as similar as when

she takes oral feeding

Every day on TPN

18

P. DISCHARGE SUMMARY AND COMMUNICATION

We have been clerking a retrospective case. However, we were only provided with the

CP2 form and there was no discharge summary provided. Thus, we were unable to

provide a summary upon her discharge from HTAR.

Based on the above discharge medication, please provide a summary of the changes

that happened in the hospital based on the DRP detected and your recommendation

given.

B. COMMUNICATION:

Please provide the communication aspects that you would give to other healthcare

professional and to patients upon discharge.

For healthcare professionals:

The healthcare professionals need to follow up the patient’s condition and

should reminds the patient to come for a follow up appointment according to

the date stated.

Should advice and counsel the patient appropriately in order to enhance the

patient adherence to medication to improve the quality of life.

Need to monitor the side effects of the medication.

For the patient upon discharge:

Advices the patient to take the right medicine at the right time stated with the

right dose and right route of administration.

Advices the patient to store the medication at the suitable place and suitable

19

temperature or condition and keep out of reach of children.

Reminds the patient for not too simply change or substitute any of the

medication prescribed.

Explains the usefulness or benefit of taking the medication and the patient must

comply all the medication to improve the quality of life and improve patient’s

condition.

Advices, counsels and educates the patient about his drug therapy which includes

the importance of compliance to the therapy as well as identify any undesired effect

caused by the therapy.

20

A method for estimating the probability of adverse drug reaction

(Naranjo CA, Busto U, Sellers EM, et al. Clin Pharmacol Ther 1981; 30:239-5.)

To assess the adverse drug reaction, please answer the following questionnaire and give the

pertinent score

Yes No Do not

know

1. Are there previous conclusive reports on this reaction? +1 0 0

2. Did the adverse event appear after the suspected drug

was administered? +2 -1 0

3. Did the adverse reaction improve when the drug was

discontinued or a specific antagonist was administered? +1 0 0

4. Did the adverse reaction reappear when the drug was

readministered? +2 -1 0

5. Are there alternative causes (other than the drug) that

could on their own have caused the reaction? -1 +2 0

6. Did the reaction reappear when a placebo was given? -1 +1 0

7. Was the drug detected in the blood (or other fluids) in

concentrations known to be toxic? +1 0 0

8. Was the reaction more severe when the dose was

increased, or less severe when the dose was decreased? +1 0 0

9. Did the patient have a similar reaction to the same or

similar drugs in any previous exposure? +1 0 0

10. Was the adverse event confirmed by any objective

evidence? +1 0 0

If score is then, ADR is:

< 0 doubtful

1 to 4 possible

5 to 8 probable

> 9 definite

21

Appendix

1. Formula creatinine clearance calculation:

a. Cockcroft-Gault GFR

(140-age) * (Wt in kg) * (0.85 if female)

(72 * Cr)

Where ClCr is expressed in ml/min, age in years, and weight in kg and serum creatinine mg/dl

If serum creatinine is expressed as µmol/liter instead of mg/dl, calculation is based on:

88.4 µmol/liter =1mg/dl

b. Estimated GFR using MDRD Equation

186 x (Creat / 88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black)

Where serum creatinine is expressed as µmol/liter

22

Q. REFERENCES

1) Drug Information Book, 22nd Edition

2) Handbook Of Medication Dosing In Renal Failure For Healthcare Professionals

3) Dipiro Pharmacotherapy Handbook

4) British National Formulary (2012)

5) NICE Guidelines On Nutrition Support For Adults: Oral Nutrition Support, Enteral Tube

Feeding And Parenteral Nutrition (2006)

6) ESPEN Guidelines On Parenteral Nutrition: Surgery (2009)

7) ESPEN Guidelines On Parenteral Nutrition: Adult Renal Failure (2009)

8) HKL Handbook Of Clinical Nutrition (2011)

9) Notes, P. (2009). Stress Ulcer Prophylaxis In The Intensive Care Unit, 75246(4), 373–

376

10) Singer, P., Berger, M. M., Van den Berghe, G., Biolo, G., Calder, P., Forbes, A., &

Pichard, C. (2009). ESPEN guidelines on parenteral nutrition: intensive care. Clinical

Nutrition, 28(4), 387-400

11) McClave S et al. JPEN J Parenteral Enteral Nutrition 2009 May-June;33(3):277-316

12) ASPEN Board of Directors. Guidelines for Use of Parenteral Nutrition in the

Hospitalized Adult Patient. Journal of Parenteral and Enteral Nutrition 26(1):1S-525,

2002

13) US Food and Drug Administration. (2013). FDA Drug Safety Communication: New

restrictions, contraindications, and dose limitations for Zocor (simvastatin) to reduce the

risk of muscle injury. Silver Springs, MD: US Department of Health & Human Services

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