Pharmacist Care Plan
Use the patient-specific data provided above to develop a comprehensive Pharmacist Care Plan that clearly identifies and assesses each acute and chronic medical and drug therapy problem in this patient. Prioritize your Pharmacist Care Plan so that the most urgent, most severe conditions are addressed first. For each medical problem include: (1) a comprehensive assessment, (2) individualized goals of therapy, (3) therapeutic recommendations including rationale and justification, and (4) monitoring plan with specific clinical endpoints and timing/frequency of follow-up.
Be sure to include pharmacist-specific interventions to address medication-related problems and ensure medication safety and efficacy(i.e., remember your ISEA MRP language). Also, consider the patient’s risk for potential medical problems and recommend appropriate disease prevention and screening activities as necessary.
Important: Only the “Pharmacist Care Plan” documented below will be assessed. The number of boxes below does not signify how many problems there are; there could be more or less. You may delete or add boxes based on the number of problems you identify.
Also, make sure to include your name and the date in the document header.
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Problem 1: Diabetic Foot Ulcer Infection |
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Assessment:KH reports feeling of some pain and discomfort that are started 8 days ago. Pt presented to emergency department with foot pain and inflammation. Pt is uncontrolled Type 2 diabetic due to costs of his medications. At ER, KH received 7-day supply of Augmentin 875/125 mg PO Q12H, and then KH reported his foot condition to be worsen during end of this therapy. KH newly diagnosed, by Dr. Oyolo,with moderate diabetic foot ulcer infection.According to 2012 IDSA, the Initial empiric antibiotic therapy should be based on the severity of the infection, history of recent antibiotic treatment, previous infection with resistant organisms, recent culture results, current Gram stain findings, and patient factors1. Per IDSA 2012, Pts may present with classic signs & symptoms of inflammation including erythema, warmth, tenderness, or pain with purulent, possibly foul-smelling, discharge from an ulcer1. These signs indicate a severe and deep infection It is important to note that pain and tenderness may be reduced in patients with neuropathy and that erythema may be decreased in patients with vascular disease1. Observing KH skin indicates positive for Wagner grade 1 diabetic foot ulcer located on dorsal side of right foot, and bilateral skin tears on plantar sides of feet. KH right foot culture results indicated MRSA susceptible to Tetracycline, Trimethoprim/ Sulfamethoxazole, and Vancomycin. KH experiencing pain of 9/10, fever body temperature of 102.2°F, and high WBC of 12 x103 cells/mm3 indicating the presence of infection. According to IDSA 2004, the empiric antibiotic regimen for diabetic foot infection should always include agents active against S. aureus, including MRSA1. In ER, KH prescribed with vancomycin and piperacillin/tazobactam for diabetic foot ulcer infection. MRP: Lab Test is Indicated; based on current KH symptoms, vital signs, labs and culture/sensitivity data, KH would benefit with completing his recently prescribed DFI antibiotic regimen. A loading dose of vancomycin 2 gm IV has already been administered. The first dose of Piperacillin/tazobactam 4.5 gm IV Q8H had been started. According to IDSA 2002, routinely prescribing antibiotics for a fixed duration may result in an insufficient or unnecessarily course of therapy. This fixed duration increases cost, potential for ADRs, and risk for antibiotic resistance. IDSA recommends the duration of antibiotic therapy for a DFI to be based on the severity of the infection, the presence /absence of bone infection, & clinical response to therapy. Goals of Therapy:
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Plan/Recommendations:
Monitoring & Follow-Up:
Potential drugsideeffects/ADRs:
Follow-up with PharmD in 1 day to evaluate the response or modify the antibiotic regimen, assess any emergence of treatment ADRs. The Pharmacists should frequently remind KH to wear socks and properly fitting closed-toe footwear. KH should moisturize and visually inspect his feet nightly, and to see a physician for evaluation of cracks, sores, and other injuries. The Pharmacist should ensure KH having the optimal blood glucose and BP control through his diet/exercise, and medication adherence. |
Problem 2: Type 2 diabetes
Assessment:KH fasting BG is 258 mg/dL and HbA1c is 9.8% (goal HbA1c: <7%). KH is diagnosed with Type 2 diabetes (T2D) in 2013. Elevated FBG likely d/t lifestyle & lack of adherence to his diabetes medications. MRP: Effectiveness: Suboptimal Regimen, KH is currently taking metformin, and his T2D is not controlled for the current medication regimen. MRP: Adherence: Failure to Receive TherapyKH reported to misses about one dose weekly. Adherence: Cost. KH reported to a clinic one year ago, and received an additional diabetic regimen but he was unable to take the medication due to cost.Per 2019 ADA Guidelines, Pt is indicated for insulin therapy to control his BG and prevent further complications of G2M including Heart and blood vessel disease such as increases the risk of heart disease, stroke, high blood pressure and narrowing of blood vessels, neuropathy, Kidney damage, Eye damage, Hearing impairment, Skin conditions, and Sleep apnea3. For patients with A1c above target on oral medications, the addition of basal or long acting insulin is a usual next step3. For our patients like KH, who have no insurance or a big copay, the most effective strategy is to get glucose to goal in a cost effective manner2.
Pt is currently on metformin 1000mg PO BID. Pt has BMI of 27.8, & eats high carb meals. Per guidelines, lifestyle modifications are the best way to lower A1c. For KH, it is a good idea to add NPH insulin to his current medication regimen and have a general notion of the cost of insulin in KH local pharmacies.
Goals of Therapy:
- Target maintain HbA1c of 6.5%,
- Maintaining fasting Blood Glucose <110 mg/dL, and 2 hr postprandial BG <140 mg/dL
- Advise eating according to DASH dietary guidelines, with attention to quantity and type of food
- Therapeutic goal is 5–10% weight loss for people who are overweight or obese with T2D
Plan/Recommendations:
- Continue metformin 1000 mg PO BID
- Upon discharge, re-initiate metformin 1000mg PO BID w/food.
- Initiate NPH insulin 10 Units daily at bedtime. This NPH dose can be monitored by PharmD and increased gradually by 2 to 3 units until KH morning blood glucose levels are below 130 mg/dl.
- Since NPH has a peak of 4-10 hours, make sure to teach about signs of hypoglycemia and treatment
- A designated Pill Box will be prepared for KH home medications.
- Encourage the KH to discontinue his alcohol consumption.
Monitoring & Follow-Up:
- Monitor pt’s BG and for s/sx’s of hypoglycemia.
- Pt should keep his daily glucose log. Complications such as the above Diabetic foot infection are due to uncontrolled diabetic management of the patient.
- Initiate nutrition therapy: increase protein & decrease carb intake.
- Keep BG log & have KH record BG upon waking, before bed & 2 hours after meals.
- Monitor for continued/worsened nocturia, Vitamin B12, liver and kidney function.
- Pt Education: Educate KH on proper insulin administration including insulin storage, injection technique and injection sites. Counsel pt on s/sx’s of hypoglycemia and how to treat. Educate pt on how and when to monitor BG (QAM and after meals), keeping a daily BG log, exercising and eating healthy.
Potential drugsideeffects/ADRs:
- Metformin: physical weakness, diarrhea, gas (flatulence), myalgia, upper respiratory tract infection, low blood sugar (hypoglycemia), abdominal pain (GI complaints), lactic acidosis, and low blood levels of vitamin B-12.
- NPH: The signs of low blood sugar such as dizziness, headache, fatigue, feeling weak, shaking, fast heartbeat, confusion, increased hunger, or sweating. Low potassium like muscle pain or weakness, muscle cramps, or abnormal heartbeat.
Follow-up with PharmD in 1 week to evaluate KH Blood glucose, his ADRS, challenges, and possible diabetic management regimen modifications.
Problem 3: Hypertension
Assessment: KH is diagnosed with HTN (since 2011). KH blood pressure in ER was 122/88 mmHg, which is at goal, of <130/80 mmHg, and KH HTN is controlled according to 2017 ACC/AHA guidelines6. Guideline recommends non-pharmacological interventions such as DASH diet5. Current KH outpatient antihypertensive medications include Lisinopril 40 mg PO daily (since 2011). MRP: Adherence: Failure to Receive Therapy. KH reported to misses about one dose weekly.
Goals of Therapy:
- Reduce cardiovascular and renal morbidity and mortality.
- Maintain BP goals of <130/80 mmHg for pts with diabetes.
- Implement healthy Dash Diet.
Plan/Recommendations:
- Continue lisinopril 40 mg PO daily
- A designated Pill Box will be prepared for KH home medications.
Monitoring:
- KH should routinely monitor his Blood pressure, heart rate
- Other monitoring parameters: BUN, serum creatinine, and potassium; consider baseline LFTs (if preexisting hepatic impairment); monitor for jaundice or signs of hepatic failure
- The American Diabetes Association (ADA) guidelines (ADA 2019) for pts with Diabetes and hypertension recommends these Pts, of 18 to 65 years of age, without ASCVD, and 10-year ASCVD risk <15% to target their blood pressure to <140/90 mmHg.
- Pt Education: EducateKH on eating a healthy balanced DASH diet of fruits, vegetables, whole grains, and low-fat dairy products w/reduced content of saturated fat, sodium and total cholesterol. KH should minimize his carb heavy dinner, and start eating lunch meals.
Potential drugsideeffects/ADRs:
- Lisinopril: dizziness, cough, headache, high potassium levels, diarrhea, low blood pressure, chest pain, and fatigue.
Follow-up with PharmD in 1 week to evaluate KH Blood pressure management and dietary modifications.
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Problem 4: |
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Assessment:
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Plan/Recommendations: Monitoring & Follow-Up: |
References:
- Lipsky BA, Berendt A, Deery HG, et al., for the Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):132-173. Available at:
https://academic.oup.com/cid/article/54/12/e132/455959. Accessed January 15, 2020.
- Obesity Management for the Treatment of Type 2 Diabetes: Standards of Medical Care in Diabetes—2018." Diabetes Care 41.Supplement 1 (2018): S65-S72. Accessed January 15, 2020.
- American Diabetes Association. Standards of Medical Care in Diabetes—2019 Abridged for Primary Care Providers. Clinical Diabetes 2019 Jan; 37(1): 11-34. https://doi.org/10.2337/cd18-0105. https://clinical.diabetesjournals.org/content/37/1/11. . Accessed January 15, 2020.
- Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014. Accessed January 15, 2020.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, Journal of the American College of Cardiology (2017), doi: 10.1016/j.jacc.2017.11.006. Accessed January 15, 2020.
- ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA. (2017). Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol (71). Retrieved from: https://www.ahajournals.org/doi/full/10.1161/HYP.0000000000000065 Accessed January 15, 2020.
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