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This text offers a practical approach to patient assessment skills in pharmacy practice. The only patient assessment text in the field written specifically for pharmacy students, this practical book relates patient assessment and clinical skills to pharmacy practice. With its breadth of content and reader-friendly design, Patient Assessment in Pharmacy Practice is an especially strong resource for pharmacy students who are about to enter their introductory clinical clerkships.
Enter your mobile number or email address below and we'll send you a link to download the free Kindle App. Then you can start reading Kindle books on your smartphone, tablet, or computer - Cited by: 1. To help readers correlate signs and symptoms of possible diseases, the book includes vital information on basic anatomy. Introduction to Patient Assessment for Pharmacists.
The e-chapter logo indicates a chapter that is currently available only online. McGraw-Hill Medical. Develop the patient assessment and clinical skills you need with the Third Edition ofPatient Assessment in Pharmacy Practice. Help your students develop the patient assessment and clinical skills they will need as pharmacists with Patient Assessment in Pharmacy Practice, 3e.
Patient assessment has five important roles in providing pharmaceutical care. First, it is essential to identify drug-related problems. About this Title. It covers basic anatomy, physiology, pathology, and body system assessments through interview, communication, and physical exams. Divided into two parts, Part I discusses global issues related.
Do you have friends or relatives you can call on for help? Who are they? Do they live close to you? Are you very involved in a religious or social group? Do you feel that God or a higher power provides a strong source of support in your life? What language do you speak at home? Do you ever feel you have difficulty communicating everything you want to say to your doctors or their staff?
European Americans Europeans have been immigrating to the United States for more than years and have diverse origins. Because European i. Thus, some of the basic beliefs regarding health and illness that dominate the American culture are described. Most European Americans view health as something more than just not being ill; they view health as a state of physical and mental well-being. If an individual is healthy, then he or she can accomplish his or her activities of daily living, will have positive energy to do things, and will be able to enjoy life.
Illness is viewed as an absence of well-being or, in other words, the presence of pain, malfunction of body organs, not being able to do what you want, a disorder of the body, or suffering as a blessing from God. Most illnesses are believed to result from infection, stress-related conditions, or improper diet. African Americans In many cases, African American health beliefs stem from traditional cultural beliefs: Illness is a lack of harmony with nature caused by evil spirits.
This notion of illness involves a disruption of the unity of mind, body, and soul. During winter, human blood should thicken as a protective mechanism. Consequently, those elderly and young persons with thinner blood become more susceptible to illness and should avoid any conditions that cause chilliness in their systems. Menstruation, digestion, and elimination help to rid the body of these impurities. Improper diet causes fluctuations of high and low blood in the body.
Colorless substances, such as vinegar, lemon juice, pickle juice, and garlic, are used to reduce high blood in the body. Traditional healers, employing different forms of magic, are used to control these undesirable human conditions.
Many African Americans value general good health, which they define as maintaining rest, exercise, and a good relationship with God and other human beings. African American spiritual healers focus on achieving physical, social, and spiritual balance in life. Other methods of treatment include the use of herbs, roots, oils, powders, and amulets. Most important, the pharmacist must work hard to win the trust of African American patients who, for the most part, perceive their interaction with the healthcare system as a very degrading and humiliating experience.
This perception is long-standing and can be traced back to the Tuskegee Syphilis Experiment. For 40 years to , the U. This study was continued despite discovering in the s that penicillin was an effective cure for this infection. Considering this history in conjunction with the discrimination and racism that African Americans experience in American society, this view is easily understandable.
Sudden fears, pretending to be ill to manipulate family, or the wrath of God may cause mental illness. Individuals who are physically sick are treated well and typically are cared for by female family members e. Physically ill patients expect to be pampered by female family members or healthcare professionals.
Male family members are responsible for logistic arrangements, such as patient transportation, financial needs, and funeral plans, rather than for caring for daily needs.
Arab Americans believe that mentally ill patients should be able to control their illness; consequently, individuals suffering from mental illness may not be treated as well. Patients are expected to be passive in any decisions regarding themselves or others. Arab Americans use home and folk remedies, such as sweating, religious rituals, herbal teas, chicken soup, and enemas; however, they also commonly respect and seek Western healthcare services and pharmaceutical medications.
Asian Americans As previously mentioned, Asian American cultures vary greatly in their beliefs and values; however, many Asian Americans are influenced by Confucian beliefs, traditional shamans, herbalists, and Chinese traditional medicine.
These beliefs include the five elements of wood, fire, earth, metal, and water, which correspond to different hot and cold seasons within the organs of the body. Good health is the proper balance between hot i.
A hot state may be caused by excessive consumption of hot foods, with symptoms of dry mouth, constipation, and exhaustion. Cold conditions result from drinking milk and eating fruits and vegetables, which can cause respiratory problems, dizziness, and blurred vision.
Other Asian Americans view disease as a result of contact with bodily fluids, corpses, or the like. Common medical problems are treated with acupuncture, coin rubbing, dietary changes, massage, exercises, steam baths, and setting of bones to name a few. In addition, those who believe that disease results from contact with bodily fluids or corpses are likely to engage in bathing rituals and to use herbal cathartics.
Hispanic Americans The U. As previously stated, individuals descended from these nations may have significantly different cultural backgrounds see Table 2. For example, a child can become sick as a result of an evil eye. Natural causes of illness include undigested amounts of food in the abdomen, which causes nausea, vomiting, and fever. Additionally, emotional, mental, and interpersonal problems can trigger illness in this belief system. For a disease caused by an imbalance in life, treatment may include foods, beverages, and medications.
Many Hispanic Americans characterize these diseases as being either hot or cold. In addition to using the Western approach of treatment, many Hispanic Americans use traditional methods of intervention, such as praying, visiting shrines, and making promises to God in return for health. Native Americans Traditional health beliefs and practices vary widely among the more than Native American tribes throughout the United States.
Thus, health is a state of harmony with self, family, friends, and nature. Harming nature is considered to be harming yourself, which results in illness. Respect for both self and nature through proper care and harmony results in good health. Illness, both physical and emotional, is caused by supernatural forces e. Some people carry objects to protect themselves against supernatural powers. Others do nothing for protection, however, because they view this form of illness as a punishment for violating tribal rules.
Healers among the various Native American tribes, known as medicine men, are believed to have psychic power to diagnose and treat illness. The goal of this healing is the restoration of harmony between the sick individual and nature.
A third type of healers can only diagnose illness. Treatment of illness includes using herbs and performing feats to recover the lost soul.
Faith healing and religion are widely used by medicine men for health recovery. Sweat baths and hot springs are used for cleansing and to provide physical relief against colds, sinus infections, and arthritis and to alleviate psychological stress.
Americans in Poverty This chapter has focused on how culture, as defined by national heritage, can affect the patient assessment process and the provision of healthcare. All the cultural variations described thus far may be viewed as barriers that may prohibit or limit our ability to provide adequate pharmacy services. In addition to the barriers of language; family relationships; and differing views on health, disease, and illness previously discussed, many Americans also suffer from the culture of poverty.
Poverty or low socioeconomic status presents significant barriers to adequate healthcare, one of which is accessibility of services. Although any individual may suffer in poverty, ethnic minorities tend more often to be members of this cultural group. Individuals of low socioeconomic status frequently seek medical assistance only after their health condition interferes with their ability to work.
On average, In this cycle, the person lives in an environment that may cause poor physical and intellectual development as well as poor economic productivity and, subsequently, poor nutrition. This leads to an increase in illness and a further decrease in productivity. In turn, all these circumstances lead to higher morbidity and accident rates, which increase healthcare costs.
The resulting high cost of healthcare then discourages the poor patient from seeking medical assistance, thereby causing more illness and decreased productivity and continuing the cycle of poverty. Accessibility In addition to limited financial resources, several factors may cause difficulty in accessing appropriate healthcare: 1 location of medical facilities, 2 transportation to these facilities, 3 immigration status, and 4 lack of insurance.
Many disadvantaged Americans must depend on family or friends for transportation to healthcare and pharmacy facilities, whether because of geographic distance or because of financial and language barriers that may prevent these individuals from using public transportation. In other words, they may not be able to communicate with the operator, to read signs and directions, or to afford the fare. Programs designed to aid the underinsured or the uninsured may not be available to individuals with a questionable immigration status.
All these factors may cause minorities to underutilize healthcare and pharmacy opportunities, which contributes to the inequality of medical care among different ethnic groups. In each area, the questions are elucidate and incorporate culturally appropriate approaches to care. E: Explanation What do you think may be the reasons you have these symptoms? What do friends, family, and others say about these symptoms?
T: Treatment What kinds of medicines, home remedies, or other treatments have you tried for this illness? Is there anything you eat, drink, or do or avoid on a regular basis to stay healthy? Tell me about it. What kind of treatment are you seeking from me? I: Intervention Determine an intervention with your patient. May include incorporation of alternative treatments, spirituality, and healers as well as cultural practices. C: Collaboration Collaborate with patient, family members, other healthcare team members, healers, and community resources.
Eliciting psychosocial context can be difficult and create great anxiety on the part of both the healthcare pharmacist and the patient. A useful mnemonic for obtaining this type of information is BATHE, which stands for background, affect, trouble, handling, and empathy. Simple questions can be used to obtain information in each of these categories. Asking how the individual feels about what is going on allows the patient to report and label what he or she is currently feeling.
The third framework that can give guidance to the provider in providing culturally competent care is LEARN. E: Explain your perceptions of the problem. A: Acknowledge and discuss the differences and similarities. R: Recommend treatment. N: Negotiate agreement. This allows pharmacists to tailor their recommendations to the individual as well as to the medical condition involved.
This will increase the level of trust between you, the patient, and the family members. Remember, in multicultural situations, you will likely face new and different sets of rules and norms.
In other words, do not impose or force your own personal and professional views and beliefs on the patient. This is the key that opens the doors of communication for understanding the world of your patient. When you recognize that these are a normal part of your experiences, you may be able to deal with them effectively.
Although your professional relationships with individuals may come to an end, you can cherish the personal relationships for the rest of your life. Previous knowledge or experience should be drawn on to assist you in asking more constructive questions—not to arrive at automatic conclusions about the patient. If you automatically assume certain qualities or form conclusions about a patient simply because he or she belongs to a particular cultural group, you risk stereotyping the patient, which you must always avoid.
Your view of a given patient should evolve from your experiences with and information gained from that patient. If you do not understand what you bring to the patient interaction or relationship i. Compare and contrast culture, ethnocentrism, prejudice, and stereotypes. What are the three most common variables that affect patient assessment?
What are the best ways to enhance cultural sensitivity when interacting with patients of different backgrounds? SJ is a year-old Muslim man who is newly diagnosed with type 2 diabetes. He has been referred to you for diabetes education. How would you handle this situation while being sensitive to cultural considerations? Skill Development Activities Cultural competence is required to achieve optimal patientcentered care and thus is a vital part of patient assessment. The exercise can be used to explore unconscious bias, bringing attention to this problem, and develop methods to work through cultural perception issues.
Louis College of Pharmacy. This game is a structured role-playing model where students experience physical, psychological, and financial problems while navigating the healthcare system. This activity can be completed collaboratively with students from other healthcare professions.
Pharmacy students can work with social work students to develop a drug plan and a plan for implementation to increase patient adherence to recommended drug therapies. The patient cases can involve a psychiatric condition in addition to a variety of other health and social conditions. Assess commonalities of disease states related to an organ system and develop a public awareness presentation about the misconceptions related to one or more of the disease states to be presented at the end of a laboratory.
Complete a brown bag review using an interpreter. Using Reflections from Common Ground, divide the vignettes among several groups. Complete the reflective exercises provided. Have groups share their insights. The effects of the cultural context of health care on treatment of and response to chronic pain and Illness.
Soc Sci Med ;— A teaching framework for cross-cultural health care. Application in family practice. West J Med ;— Bigby JA, ed.
Cross-Cultural Medicine. Philadelphia: American College of Physicians, Am J Health Syst Pharm. Cutilli CC. Do your patients understand? Providing culturally congruent patient education. Orthop Nurs ;25 3 — Davis C. Thorofare, NJ: Slack, Kavanagh K, Kennedy P. Thousand Oaks: Sage Publications, King TE.
Wheeler MB. New York: McGraw-Hill, Culturally and linguistically appropriate services—advancing health with CLAS. N Engl J Med ;— Kreps G, Kunimoto E. Ethnic: a framework for culturally competent clinical practice.
In Appendix: useful clinical interviewing mnemonics. Patient Care ;34 9 — Lincoln B. Reflections from Common ground. Cultural Awareness in Healthcare. Nursing across cultures: the Vietnamese client.
Home Healthc Nurse ;— Ludwig-Beymer PA. Transcultural aspects of pain. Transcultural Concepts in Nursing Care, 3rd ed. Philadelphia: JB Lippincott, Lynch E, Hanson J. Developing Cross-Cultural Competence. York, PA: Paul H. Brookes Publishing, Providers guide to quality and culture: medical history and diagnosis. Accessed December 30, National Center for Cultural Competence.
Accessed September 10, Paniagua FA, ed. Assessing and Treating Culturally Diverse Clients, 4th ed. San Francisco: Jossey-Bass, Purnell LD. Guide to Culturally Competent Health Care, 3rd ed. FA Davis Company, Barriers to the use of pharmacy services: the case of ethnic populations.
J Am Pharm Assoc. J Am Acad Nurse Pract ;17 9 : — Spector RE. Cultural Diversity in Health and Illness, 8th ed. National healthcare quality report, Culture, language and health literacy. National standards for CLAS in health and health care. Knezevich This chapter includes material written for the second edition by Rhonda M. Because this is such an integral part of current pharmacy practice, the pharmacist must be able to communicate appropriately with patients as well as with other healthcare professionals.
Pharmacists must accurately obtain patient health and medication histories because they are an integral part of the initial patient assessment process in the community and ambulatory settings as well as after admission into a hospital, assisted living facility, or nursing home. Furthermore, the Joint Commission on Accreditation of Healthcare Organizations JCAHO is now requiring healthcare providers to reconcile medications upon admission, during transfers between levels of care, and upon discharge to avoid medication errors that frequently occur during these situations.
To elicit useful information, the pharmacist must use appropriate interviewing skills. The Environment Before a pharmacist talks to a patient or obtains any physical assessment data e. The interaction may occur in a variety of settings, such as a community pharmacy, hospital room, or clinic examination room. However, basic environmental characteristics should be consistent from setting to setting to assist with ensuring a smooth and productive pharmacist—patient interaction.
As illustrated in Figure 3. Open-Ended Questions Open-ended questions require the patient to respond with a narrative or a paragraph format rather than with a simple yes or no. These types of questions elicit open expression, allowing the patient to answer in any way that he or she wishes. They allow the patient to give the pharmacist information from his or her perspective. Open-ended questions are useful in gathering less-structured patient information.
All barriers should be removed between the pharmacist and the patient e. In the hospital setting, the pharmacist should be seated at eye level with the patient for a face-to-face interaction.
Standing over a bedridden patient may imply superiority, possibly causing the patient to feel both inferior and uncomfortable. Opening Statements The opening statements between the pharmacist and the patient set the stage for the interaction. The patient should be addressed by his or her surname if known. If the patient does not already know him or her, the pharmacist should introduce himself or herself and explain the reason for the interaction.
In addition, the patient should be told the approximate amount of time that the interaction will take. Mark Davis, the pharmacist. I want to talk to you to see how you are doing on your medication. It should only take a few minutes. An additional, brief explanation for the interaction usually resolves any confusion.
Types of Questions Following the brief introduction, the pharmacist should ask the patient various questions. For an efficient yet productive patient—pharmacist dialogue, these should include a combination of open-ended and closed-ended questions.
Open-ended questions may provide more detail than is needed, however, or they may not provide enough. They are most useful in beginning a patient interview, introducing a new section of questions, and switching to a new topic. Closed-Ended Questions Closed-ended questions, or direct questions, ask for specific information and details.
They elicit short, one- or two-word answers e. They also may be useful in speeding up the interaction because several minutes—or even hours—may be needed when asking only open-ended questions, which fail to provide needed details. Overusing closed-ended questions, however, may lead to an air of interrogation and impersonality, which displays a negative attitude toward the patient.
In addition, overuse of closed-ended questions may limit the data obtained and result in an inaccurate assessment. Thus, a combination of open-ended and closed-ended questions is usually the most efficient and productive way of obtaining needed patient information, as shown by the sample interaction between a pharmacist and a patient in Box 3.
My name is Monica Smith, the pharmacist. I want to talk to you about your medications. Patient: Okay. An empathic response identifies a feeling, which is then reflected back to the patient in an understanding, caring, and nonjudgmental way. My current doctor always seems too busy to talk to me! Adams prescribed that new medication? Patient: Oh, I guess alright. Some days I feel lousy, and some days I feel good. Facilitation 3. Do you feel weak or tired?
Pharmacist: Do you have any difficulty breathing at other times during the day or when you lie down at night? Several feedback techniques can be useful in assisting the pharmacist with both these processes.
These techniques include 1 clarification, 2 reflection, 3 empathy, 4 facilitation, 5 silence, and 6 summary. Clarification Clarification is useful if the patient provides confusing or ambiguous information. It can also help in providing the pharmacist with more specific details.
It shows that the pharmacist is interested in what the patient is saying and wants the patient to continue. The conversation can be facilitated both verbally e.
Silence When being questioned, occasionally the patient will need time to think and to organize what he or she wants to say. The pharmacist should become comfortable with these pauses as a necessary part of the communication process.
A long pause, however, could be caused by the patient not understanding or hearing the question; in this case, the pharmacist may need to repeat the question. Summary A summary is a review of what the patient has communicated. Is that correct? Elements of nonverbal communication include 1 distance, 2 body posture, 3 eye contact, 4 facial expressions, and 5 gestures.
For a successful pharmacist—patient encounter, the verbal and the nonverbal communication must be in congruence. This is very important in establishing rapport with the patient. Distance The distance between the pharmacist and the patient plays an important role in a successful interaction. The 18 in surrounding the body is the most protected space, so a distance closer than this may cause the patient to feel both nervous and uncomfortable.
Frequently, patients will communicate nonverbally their comfort level with the distance e. The pharmacist should note this and adjust his or her distance accordingly. The legs should be comfortably apart, not crossed, and the arms should be at the side. This type of posture may shorten or discontinue productive communication between the pharmacist and the patient and, thus, should be avoided. Eye Contact Appropriate eye contact does not mean continuously staring at the patient.
Instead, the pharmacist should spend most of the interaction looking directly at the patient and only occasionally looking away. This is a very important aspect of good patient interviewing skills. Not looking at the patient may send a message of disinterest and lack of caring. It is important to note, however, that in some cultures, direct eye contact is considered inappropriate and the pharmacist should take that into consideration when counseling patients.
A review of cultural differences to consider is included in Chapter 2. If the two do not match, the patient will tend to believe the facial message more than the spoken words. Appropriate facial expressions should reflect an attentive, sincere, and caring interest in the patient. Doing so may risk the trusting relationship between patient and pharmacist. Gestures Gestures also send nonverbal messages regarding emotional feelings or physical symptoms. As with other nonverbal communication, the gestures should match the verbal message.
The pharmacist should always be conscientious regarding any gestures that may be distracting to the patient. Closing Statements Bringing the interview to an appropriate close is a crucial part of the communication process. Many times, the patient will evaluate the entire interaction based on the final statements; therefore, the pharmacist should not end the interview abruptly.
An effective way to close the interaction is to provide a brief summary. This allows both the pharmacist and the patient an opportunity to review what has been discussed and to clarify any misinformation. Once both parties have determined that the information is correct, the pharmacist can conclude with a simple, closed-ended question e.
If you have any questions when you get home, please call me. Nonverbal cues e. These errors may decrease the amount of data obtained from the patient and hinder the development of rapport. Because of their defeating nature, such responses should be avoided when obtaining information from the patient. These include 1 changing the subject, 2 giving advice, 3 providing false reassurance, 4 asking leading or biased questions, and 5 using professional terminology.
Changing the Subject Many times, the pharmacist may encounter a situation in which he or she is unsure of how to respond. In this case, the easiest way out is to change the subject e. In such a situation, however, patients are likely to feel as if their concerns were not heard or understood.
The pharmacist also should avoid using this response when rushed for time or anxious to obtain specific patient information.
Changing the subject should be used only when all appropriate patient information has been gathered concerning one topic and it is time to move on to the next. Giving Advice Patients frequently will ask the pharmacist for advice concerning medications or various health problems.
Do you think it is diaper rash or an allergic reaction to the antibiotic she started yesterday? When appropriate, the pharmacist should provide patients with sufficient medical information e. Providing False Reassurance When discussing anxiety-inducing health concerns with a patient e. This falsely comforting response may make the pharmacist feel better; however, it may make the patient feel as if he or she should not be upset, worried, scared, frustrated, and so on.
This falsely reassuring response also may close off further communication between the pharmacist and the patient. Using Professional Terminology Many patients do not understand commonly used pharmaceutical and medical terms e. For effective communication, the pharmacist should use words with which the patient is familiar. The purpose of the health history is to obtain subjective patient information or, in other words, what the patient says about his or her own health, medications, and so on.
In the institutional setting e. In the ambulatory or community setting, the pharmacist may obtain the health history. The patient usually provides his or her own health history. If the patient cannot provide reliable information, however, then a family member, friend, caregiver, or interpreter can be used as the source. Chief Complaint The chief complaint CC is a brief statement of why the patient is seeking care.
The best way to elicit the CC is by using an open-ended question e. Occasionally, the patient may not have a CC. For example, the patient may be unable to speak e. Through this process, a hidden CC may be discovered. Specific characteristics should be routinely obtained regarding all the presenting symptoms. Has it happened in the past and what was the outcome? Hospitalizations, surgical procedures, accidents, injuries, and obstetric history for women also are included, along with the approximate dates and duration if known.
These data typically include status i. Alcohol consumption is documented as the type, amount, pattern, and duration of alcohol use e. To describe the drinking habits of patients who drink only when dining out or at social gatherings, the term social drinking is sometimes used. This term is open to wide interpretation, however, and should be clarified regarding the specific type, amount, pattern, and duration of alcohol ingestion. For patients who drink regularly, the date and time of the last drink also should be documented.
Tobacco use is quantified by the type of tobacco consumed i. For example, a 20 pack-year smoking history may mean that the patient has smoked 1 ppd for 20 years or 2 ppd for 10 years.
Because a given pack-year measurement can include a wide variation in actual smoking habits, the pharmacist should record both the pack-year and the packs per day e.
A history of illicit drug use, also known as recreational or street drugs, may be difficult to obtain from the patient. The pharmacist should use professional, nonjudgmental communication techniques when asking these questions. As with alcohol and tobacco use, illicit drug use also is documented as the type, amount, pattern, and duration of use. The date of the last drug use also should be recorded.
The number of meals and snacks typically consumed on a daily basis, as well as the type and quantity of food, should be documented. In particular, the percentage of red meat, fat, fiber, and salt consumed on a daily basis should be obtained. Exercise should be recorded as the type, frequency, and duration of activity. The pharmacist should consider these factors for both physician referral decision making and pharmacotherapeutic planning.
For example, an unemployed patient may be at high risk for nonadherence if he or she cannot afford an expensive medication. Review of Systems The review of systems ROS is a general description of patient symptoms per body system.
The questions to elicit this information typically are closed-ended and ask about the occurrence of common symptoms regarding each system. The order of questioning typically follows a head-to-toe format. The purpose of the ROS is to identify any additional symptoms or medical problems not yet revealed by the patient during the CC, HPI, or PMH and to guide the pharmacist in gathering needed physical exam and other objective data. Both the presence and the absence of symptoms should be noted.
In addition to the names of these medications, obtain the dosage, dosing schedule, duration of therapy, reason for taking the medicine, and outcome of therapy. It is best to use an open-ended question to elicit the most accurate patient information. A leading question e. Therefore, leading questions should be avoided. Some patients may not know the names of their current medications. If this happens, have the patient describe what the medicine looks like, with as much detail as possible.
This description should include the dosage form; the size, shape, and color; and the numbers, letters, or words on the dosage form. The pharmacist also must obtain the prescribed dosing schedule e. If the patient is not taking the medication as prescribed e. One way to obtain this information is to ask the patient how many doses he or she consumes in a day, a week, or a month. Asking the patient how often he or she has to obtain a new supply of medication may be useful as well.
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