Tiêu đề 2. INTRODUCTION TO DAILY ACTIVITIES OF A CLINICAL PHARMACIST.pdf ✅

PHARMD GURU Page 2 TDM IS USEFUL IN DRUGS: 1. With a narrow therapeutic index. 2. Which is highly protein bound. 3. Which are liable to interact? 4. In which the metabolite might be toxic. ROLE OF PHARMACIST IN THERAPEUTIC DRUG MONITORING: A reliable and responsive TDM service depends on team work between nurses, doctors, pharmacist, scientist and technical staff. The clinical pharmacist should provide advice to medical staff on the appropriate use and timing of TDM and assist with the interpretation of results. In addition the pharmacist maybe involved in: 1. Initial selection of drug regimen. This may involve decisions about drug choice, dose, dosing interval, route of administration and dosage form of the drug, taking into account factors such as sex, age, body weight, race, metabolism status, renal function, plasma albumin concentration, use of other drugs and laboratory results. 2. Adjustment of the dosage regimen based on TDM results and the patient’s clinical response. 3. Assessment of possible causes for unexpected results, such as non- compliance, bioavailability problems, medication errors, drug interactions or pharmacogenetic variability. 4. Dose adjustment for patients on hemodialysis or peritoneal dialysis. 5. Provision of poisons information. MEDICATION CHART REVIEW: 1. It is a fundamental responsibility of a pharmacist to ensure the appropriateness of medication orders. 2. It serves as starting point for other clinical pharmacy activities (medication counseling, TDM, DI, and ADR). 3. Organizing information according to medical problems (example disease) helps breakdown a complex situation into its individual parts.
PHARMD GURU Page 3 AIMS: 1. To optimize the patients drug therapy. 2. To prevent or minimize drug related problems/medication errors. PROCEDURE: 1. The patient’s medical record should be reviewed in conjugation with the medication administration record. 2. Recent consultations, treatment plans and daily progress should be taken into account when determining the appropriateness of current medication orders and planning each patient’s care. 3. All current and recent medication orders should be reviewed. COMPONENTS OF MEDICATION ORDER REVIEW: It includes: 1. Checking that medication order is written in accordance with legal and local requirements. 2. Ensuring that the medication order is comprehensible and unambiguous, that appropriate terminology is used and that drug name are not abbreviated. Annotate the chart to provide clarification as required 3. Detecting orders for medication to which the patient may be hypersensitive/ intolerant. 4. Ensuring that medication order is appropriate with respect to:  The patient’s previous medication order.  Patient’s specific considerations e.g. disease state, pregnancy.  Drug dose and dosage schedule, especially with respect to age, renal function, liver function.  Route, dosage form and method of administration. 5. Checking complete drug profile for medication duplication, interactions or incompatibilities. 6. Ensuring that administration times are appropriate e.g. with respect to food , other drugs and procedures. 7. Checking the medication administration record to ensure that all ordered have been administered.