medication teaching what parents should know nadya nalli, bsc.phm paediatric academic multi organ...

Medication TeachingMedication Teaching

What Parents Should KnowWhat Parents Should Know

Nadya Nalli, BSc.PhmNadya Nalli, BSc.Phm

Paediatric Academic Multi Organ Transplant PharmacistPaediatric Academic Multi Organ Transplant Pharmacist

The Hospital for Sick ChildrenThe Hospital for Sick Children

Pharmaceutical CarePharmaceutical Care

Pharmacist Pharmacist • Accepts that he/she will be directly Accepts that he/she will be directly

responsible to the patientresponsible to the patient

PatientPatient• becomes a partner in care rather than becomes a partner in care rather than

recipient of carerecipient of care

Paediatric PracticePaediatric Practice

SpectrumSpectrum• Neonate Neonate adolescent adolescent

Patient & parent/caregiver dynamicsPatient & parent/caregiver dynamics

Medication teachingMedication teaching

Who Who == audienceaudience WhyWhy== purposepurpose WhenWhen == urgencyurgency WhatWhat == contentcontent HowHow== mediamedia

WHO? / AudienceWHO? / Audience

Adult vs childAdult vs child

• Learning capacity Learning capacity Age variantAge variant

• StyleStyle Several theories (adult and child)Several theories (adult and child) Operational stages (Piaget)Operational stages (Piaget) Learning Style InventoryLearning Style Inventory

AudienceAudience

• Experience/perspectiveExperience/perspective Acute vs chronic illnessAcute vs chronic illness Cultural differencesCultural differences

• LanguageLanguage fluencyfluency

AudienceAudience

TerminologyTerminology

• common vs medicalcommon vs medical• definition of termsdefinition of terms• acronyms/short formsacronyms/short forms• familiarity with systemfamiliarity with system

Why? / PurposeWhy? / Purpose

Although essential in disease Although essential in disease management, if taken improperly, management, if taken improperly, medications can also be the source medications can also be the source of significant morbidity and mortalityof significant morbidity and mortality

Major underlying causes of patient Major underlying causes of patient adverse drug events have been adverse drug events have been associated with defects in drug associated with defects in drug knowledge disseminationknowledge dissemination

PurposePurpose Non-compliance and drug misadventure are more Non-compliance and drug misadventure are more

likely to occur when patients are prescribed many likely to occur when patients are prescribed many medicationsmedications

Drug misadventure is more likely when patient Drug misadventure is more likely when patient medication regimens are changed.medication regimens are changed.

One should not consider possible risks associated One should not consider possible risks associated with taking particular medicines in isolation from with taking particular medicines in isolation from the likely beneficial effects. For most people there the likely beneficial effects. For most people there will be only a single benefit that is sought, but the will be only a single benefit that is sought, but the potential risks are often multiple.potential risks are often multiple.

PurposePurpose

Pharmaceutical Care has been the Pharmaceutical Care has been the pharmacist’s approach to improving pharmacist’s approach to improving medication usemedication use

Pharmaceutical care is the Pharmaceutical care is the responsible provision of drug therapy responsible provision of drug therapy designed to meet a designed to meet a defineddefined outcome outcome individualizedindividualized for a specific patient. for a specific patient.

When? / UrgencyWhen? / Urgency

Stress is a barrier to learningStress is a barrier to learning

Prioritize information Prioritize information

FlexibilityFlexibility

Follow-up Follow-up

What? / ContentWhat? / Content

Reason for useReason for use• goals of therapygoals of therapy• time frame of effecttime frame of effect

Schedule Schedule • dose time; potential for flexibilitydose time; potential for flexibility• drug-drug, drug-food, drug-disease issuesdrug-drug, drug-food, drug-disease issues

ContentContent

Potential/expected adverse effectsPotential/expected adverse effects• monitoring at homemonitoring at home• urgencyurgency

Management of adverse effectsManagement of adverse effects• planplan

ContentContent

Dose AdministrationDose Administration

• route (po/pr/ng,gt,jt/topical/sc/iv)route (po/pr/ng,gt,jt/topical/sc/iv)• dose form manipulationdose form manipulation• strategiesstrategies• problem solving skillsproblem solving skills

ContentContent

Drug coverageDrug coverage

• ODB (Trillium/HCP/WF) or private planODB (Trillium/HCP/WF) or private plan• OOP (out of province) patientsOOP (out of province) patients• fiscal year/family capfiscal year/family cap• co-payco-pay• Rx vs OTCRx vs OTC• paperwork (LUF vs. sect 8 approval)paperwork (LUF vs. sect 8 approval)

MediaMedia

Verbal summaryVerbal summary

Verbal + written summariesVerbal + written summaries

Innovative materialInnovative material• Colour codingColour coding• BrailleBraille

Medication scheduleMedication schedule

Teaching & Self Medications Teaching & Self Medications 6A/4D6A/4D

BackgroundBackground

• Paediatric Academic Multi-organ Paediatric Academic Multi-organ TransplantTransplant

• 40+ transplants/year (heart, lung, liver, 40+ transplants/year (heart, lung, liver, kidney and small bowel)kidney and small bowel)

• single or combinedsingle or combined• Deceased donor or living related*Deceased donor or living related*• full organ or split*full organ or split*


Philosophy: Philosophy: • learning occurs in an environment learning occurs in an environment

where safeguards and resources are where safeguards and resources are available in order to optimize careavailable in order to optimize care

• family-centred carefamily-centred care

• multi-disciplinary approachmulti-disciplinary approach


ConsentConsent

• discuss goals of program with discuss goals of program with caregiver(s) and or patient (if age caregiver(s) and or patient (if age appropriate)appropriate)

• obtain written consent; place in chartobtain written consent; place in chart• set a time that is mutually convenientset a time that is mutually convenient• determine need for interpreterdetermine need for interpreter


TeachingTeaching

• initially didactic (~ 1 hour)initially didactic (~ 1 hour)• progression to didactic/interactive progression to didactic/interactive • limit setting by caregiver re: amount of limit setting by caregiver re: amount of

information given per sessioninformation given per session• follow-up sessions as requiredfollow-up sessions as required• documentation!documentation!


Medication SummaryMedication Summary

• individualizedindividualized• includes standard oral/iv medicationsincludes standard oral/iv medications• includes name(s), reason for use, includes name(s), reason for use,

adverse effects and special instructionsadverse effects and special instructions

CaseCase 7 yr old male; 2 weeks post renal tx7 yr old male; 2 weeks post renal tx

• Tacrolimus 3mg po q12hTacrolimus 3mg po q12h• Mycophenolate mofetil 250mg po q12hMycophenolate mofetil 250mg po q12h• Prednisolone 5mg po dailyPrednisolone 5mg po daily• Trimethoprim sulfamethoxazole 60mg po q Trimethoprim sulfamethoxazole 60mg po q

dailydaily• Nystatin 100,000u swish/swallow qidNystatin 100,000u swish/swallow qid• Ganciclovir 150mg iv dailyGanciclovir 150mg iv daily• Magnesium hydroxide 400mg++ po bidMagnesium hydroxide 400mg++ po bid• Phosphate sodium 15mmol po bidPhosphate sodium 15mmol po bid• Ranitidine 75mg po qhsRanitidine 75mg po qhs

Medication Summary for Medication Summary for Transplant Transplant Patient, Patient, July 2004July 2004

Name of Drug What is it For? Side Effects Special Instructions

Tacrolimus (FK) (Prograf)

- to prevent rejection

- tremors - may blood pressure - may magnesium levels - may potassium levels - kidney damage (dependent on level) - seizure (dependent on level) - may cause hair loss

- take dose on time - take with food or juice (no grapefruit juice) or on an empty stomach, but always take it the same way. - if vomit dose in: <1/2hr: take again 1/2-1hr: take 1/2 amount > 1hr: do not need to re-take *Repeat dose only once* - if diarrhea tell transplant nurse - check with the transplant nurse first before starting any new medicine - 0.5mg, 1mg, 5mg capsules, also 0.5mg/ml HSC suspension that is stored at room temperature and must be shaken before each dose - FK blood levels are measured in the morning before your morning dose


Accommodation of PreferencesAccommodation of Preferences

• dose form (solid vs liquid)dose form (solid vs liquid)• dose form (size vs volume)dose form (size vs volume)• dose schedule (where applicable)dose schedule (where applicable)


Medication Administration Record Medication Administration Record (MAR)(MAR)

• individualizedindividualized• double checkeddouble checked• updated every shiftupdated every shift• adaptable, where possibleadaptable, where possible

Medication Schedule for Medication Schedule for Transplant PatientTransplant PatientTime Medication Mo Tue We Thu Fri Sat Sun 8am Tacrolimus (FK)

(0.5mg/ml susp’)

Mycophenolate mofetil (MMF) (100mg/ml susp’n)

Prednisolone

(1mg/ml liquid) Cotrimoxazole

(8mg TMP/ml susp) XXX XXX XXX XXX

Nystatin (100,000u/ml susp)

11am Magnesium

hydroxide (33mg++/ml susp)


MedicationsMedications

• individualizedindividualized• 7 day supply7 day supply• provided in lock box (room temp meds)provided in lock box (room temp meds)• template for optimal storagetemplate for optimal storage


Drug PlanDrug Plan

• determine type & extent of drug coveragedetermine type & extent of drug coverage• if private, give DINS to parents if private, give DINS to parents • if ODB, identify limited use if ODB, identify limited use vsvs sect. 8 sect. 8 vsvs

fullfull• if OOP patient, identify all potential payorsif OOP patient, identify all potential payors


Drug PlanDrug Plan

• explore compassionate supply avenuesexplore compassionate supply avenues• referral to Trillium if required (Ontario referral to Trillium if required (Ontario

patients only)patients only)• liaise with social worker (if required) and liaise with social worker (if required) and

discharge plannerdischarge planner


Life IssuesLife Issues

• concomitant/new medicationsconcomitant/new medications• alcohol/recreational drug usealcohol/recreational drug use• sexual activitysexual activity• traveltravel


Discharge Prescription -Discharge Prescription - continuity of continuity of carecare

• ensure appropriate drug/doseensure appropriate drug/dose• ensure optimizations/preferences includedensure optimizations/preferences included• communicate with outpatient pharmacy to communicate with outpatient pharmacy to

ensure medication supply, convey ensure medication supply, convey information (patient/caregiver consent)information (patient/caregiver consent)

medication teaching what parents should know nadya nalli, bsc.phm paediatric academic multi organ...

Documents

patient medication regimens

specific patient

purposepharmaceutical

potential risks

likely beneficial effects

age appropriateobtain

disease management

medicationsdrug misadventure