Community Pharmacy Placement Exercise - Assignment Example

Community Pharmacy Placement Exercise Physical Environment The pharmacy where I had my placement was the Hawker Pharmacy. It is located in North Canberra, in the suburbs of Hawker. The pharmacy is surrounded by many small shops and businesses servicing the people living in the area. There is a supermarket in the area along with several restaurants and food establishments, a hair dresser, a news agent, and a bakery shop. People most frequently patronize the supermarket and the food establishments in the area. The nearest medical centre, which is the Hawker Medical Centre, is located very near the pharmacy and there are also several Dentist medical surgeons located very near the pharmacy. There is also a complementary Health Centre which also offers services as a pharmacy. This is the only pharmacy in the area and the next pharmacy is located in the next suburb. The Hawker Medical Centre and Dentist Medical Centre complement the services provided by the pharmacy. The nearest public toilet is located across the road from the Hawker Pharmacy. The pharmacy is located near the bus stop and the taxi rank, making it very convenient for customers and employees to access. A large-sized car park is located in Hawker place, which is the main street in the Hawker suburbs. There is no Justice of the Peace in the pharmacy. I have been lucky to do my placement in Hawker pharmacy because it is very convenient for me as I live near it and it offers many advantages for learning. How well do you think the pharmacy fits in with the surrounding community? Why is this important? This pharmacy fits in the surrounding community because the area is relatively new and is the only pharmacy located in the area. Professional and Retail Services and Products From a customer’s perspective, I was able to assess the pharmacy’s services and I concluded that the pharmacy is able to provide a wide-range of retail services including skin and hair products; gift items; and glass wear. The pharmacy is also able to offer professional health services through its pharmacists and pharmacy assistants. These services are mostly related to medicine intake and health maintenance advice. The pharmacy is able to provide health related products through its first aid program and methadone program. It is also able to cater to diabetics through its blood-sugar control and blood-sugar testing program. The overall message that I got from the pharmacy, in terms of the services and products it offers, is that the pharmacy is available and eager to care not just for the customers who are sick, but also for those who seek to maintain their health. The pharmacy also provides the customers with other services that they need in order to stay healthy. I would definitely offer similar services in a pharmacy I owned because the services offered are very convenient and are health-related. There are some differences in my perception (as a patient) and that of the interviewed staff member. The staff member I interviewed feels that one of the more important services that the pharmacy can improve would be its methadone and diabetic program. As a customer, I found it convenient for the pharmacy to have gift products and glass wear because such services were not seen in the area. I believe these differences are there because, from my point of view as a customer, I seek convenience in services. I want to be able to accomplish tasks and errands without wasting my time trying to find establishments that can cater to my different needs. But the staff in the pharmacy deals everyday with customers who are not healthy, who are overweight and obese. And with this perspective, they feel that their services as a member of the medical community can be expanded to help prevent and reduce obesity and the number of diabetic patients. The impact that these differences could have on the success of the pharmacy as a business is very different. If it were to improve more on its weight loss and diabetic program, its impact would be more on the health of the people. Initially, it would be able to improve its profit from its weight loss and diabetic program, but as people will start improving on their health, there would be less obese and diabetic people. As a result, profits on medicines for obese and diabetics would decrease. As a provider of health care, the staff’s opinion about improving our health services for the weight loss and the diabetic program is indeed more advantageous and beneficial. The ages of the customers were mostly 60 and above, of varied ethnic backgrounds but mostly of Italian and Greek descent. They were mostly single with small family sizes. Their socio-economic status appears to be under the target as they appeared to be not well-dressed. Majority of the customers were retired from working in the government and were not well-educated. Most of our customers were regulars and were very familiar and comfortable interacting with our pharmacist. This pharmacy is just a perfect example of a community pharmacy which offers services to the patient in an area surrounded area by friendly staff members and elderly patients. How does this information affect the way the pharmacy operates and the services it offers? Do you think they should be called customers, clients, patients or something else? This is a hard question to answer. I prefer to call them patients not customers because the main purpose of the pharmacy profession is to deliver health care and counselling to patients; it is a profession which is not supposed to be driven by the dollars only. There are two entrances to the pharmacy, the dispensary area in front facing any customer coming to the pharmacy. This service counter has enough room for the patient to move around. There is also a special area for patients in the methadone program and there is also an open counselling area for the patients. In the counter area, there are signs to distinguish between health and non – health related products. The layout of the pharmacy is very well organized and one can easily find what one is looking for. Also, the placement of products in the pharmacy is not crowded and they are stocked properly based on medicine and storage specifications. Case study: Applied Therapeutics 1 Q1. Define GORD. GORD stands for Gastro-oesophageal Reflux Disease. It is a condition in which the “stomach contents (liquids/food) leak backwards from the stomach into the oesophagus” (Longstreth, 2009). In cases of irritation of the oesophagus, there is heartburn (burning or irritant sensation felt radiating up the middle of the chest) caused by the gastric reflux (literally, regurgitation of acid, pepsin, or bile) (Walker, 2007, p. 159). Food passes from the throat to the stomach through the oesophagus. Once food is in the stomach, a ring of muscle fibres prevents food from moving backward into the oesophagus; and this muscle is known as the lower oesophageal sphincter or the LES. In cases when this sphincter does not close well, the stomach contents leak back into the oesophagus and this is called pastrophageal reflux. This reflux can damage the oesophagus. The most common symptoms for GORD are nausea after eating. Some people feel like they have food trapped behind their breath bone. Burning pain in the chest, most especially at night, and during bending or lying down is also felt. Other symptoms include belching, upper abdominal discomfort, bloating, and cough. In addition to heartburn and regurgitation, respiratory, pharyngeal, and laryngeal symptoms may also manifest. Sleep disturbance may also be seen. Alarming symptoms for this disease include anaemia, dysphagia, odynophagia, haematemesis, melaena, vomiting, and unexplained weight loss. Risk factors for GORD include obesity. Strong evidence indicates a connection between GORD and obesity. Obesity usually causes more pressure around the stomach. Another risk factor is that of smoking tobacco which can cause irritation in the oesophagus. GORD can often be made worse by various medications such as anticholinergics, beta blockers, bronchodilators, calcium channel blockers, and tricyclic antidepressants. An endoscope can be used in order to confirm GORD. This endoscope is used to identify the cause and to examine the oesophagus for damage by inserting a tin tube (with a camera on one end) into the mouth, passing through the oesophagus and on to the stomach and intestines. GORD is a condition which must be treated immediately in order to avoid complications such as Barret’s oesophagus (change in the lining of the oesophagus which may lead to an increased risk for cancer), Zollinger-Ellison syndrome, bronchospasm (due to irritation and spasm of airways), oesophagus ulcer, inflammation of the oesophagus (oesophagitis), and scleroderma (which causes strictures and disorders of oesophageal motility). Q2: The effects of the initial treatment of GORD associated with oesophagitis are: Initial treatment should be tailored according to the severity of the presenting symptoms. Such treatment should control, relieve symptoms, and allow healing of the inflammation; it should reduce the risk of developing complications with less financial cost. If symptoms occur once or twice a week, these symptoms are considered as mild intermittent symptoms. Advice should be given for the patients to follow non-pharmacology therapy and change in lifestyle. There is enough evidence that limiting the following: alcohol, high fat meals, chocolates, coffee, oranges, grape fruits, lemons, tomato products, and spicy foods can decrease incidence of GORD. These are foods which increase the acidity of the stomach. The patient can also be advised to take in small meals which are low in fat. These foods can limit the amount of acid produced in the stomach. Exercise can also assist in the decrease of incidence of GORD as it decreases the amount of abdominal fat which in turn decreases the pressure exerted on the stomach. The patient can also be advised to elevate the bed head and to avoid eating or drinking for at least 2-3 hours before bedtime. These lifestyle modification techniques can decrease the risk of regurgitation of stomach contents into oesophagus thus decrease the risk of oesophagitis. Antacids can also be taken on a required basis after meals in order to relieve symptoms of heartburn (associated with stomach contents irritating the oesophagus). These antacids have a short duration of action; therefore they need to be taken frequently. Antacids work by neutralizing stomach acids into their subsequent salt and water produce elements. However, such antacids may cause constipation because of their aluminium, magnesium, and sodium bicarbonate contents which are all base. If the symptoms still persist or the patient has symptoms of GORD two or more times in a week, an endoscopy, stool culture, urea breath test may be necessary in order to detect H. Pylori and to confirm such diagnosis. In this case, a triple therapy must be initiated. This therapy includes the proton pump inhibitor (to inhibit the parietal cells so less acid will be produced and ulcer can heal); an antibiotic (amoxicillin to destroy H. Pylori cell wall, metronidazole for those allergic to penicillin, clarithromycin antibiotic. If H. pylori is not detected, then PPI medications alone can be administered. The PPI can reduce the amount of acid produced by the stomach. They also work by inhibiting the H+/K+/ATpase pump. PPI can also help in the healing of oesophagitis because it reduces acid secretion. In this case, a high acid content in the stomach cleaves pepsinogen to pepsin. When pepsin is regurgitated into the oesophagus, inhibition of H+ stops the digestive process and allows the oesophagus to heal. The initial course of treatment should be 4-8 weeks in duration. The patient can be given the PPI agent esomeprazole 20 mg orally, once daily in the morning. If symptom response is inadequate and endoscopy excludes other diseases, and no other causes for the symptoms are found, the dosage for esomeprazole may be doubled. There is evidence to prove that a higher dose of proton pump inhibitor therapy is more effective than if it were to be given twice daily (TGA). There is also a need to review treatment for possible adjustments of further referrals. Q3. What are the effects of maintenance treatment of GORD associated oesophagitis? The aims of maintenance therapy are to control symptoms; to reduce the risk of developing complications; and to minimise cost. It may therefore lead to a number of strategies. If there is a good response in the initial course of treatment, then the PPI can be switched to fit the requirements. The failure to achieve adequate symptom control may indicate a need to recommence regular medication. Alternative treatments may be titrated down and continued at the lowest dose. The end point is the control of the symptom and the patient response to titration provides good compliance. In some cases 20mg daily of H2 antagonists (Famotidin) may also be used as medication. Famotidine inhibits the action of gastrin on parietal cells (binding of gastrin to parietal cells stimulates H+ release into the stomach to lower the pH and make the stomach environment acidic). H2 antagonists help maintain treatment if the patient experiences mild symptoms or if the patient is resistant to PPI. The lowest possible dose of the Famotidine must be used for symptomatic relief. If the symptoms cannot be controlled by the medical therapy or if symptoms are derived from a large hiatal hernia, then surgical therapy may be considered. Patient selection is important to the outcome of surgical treatment. The decision therefore must be based on patient choice in relation to the risks and benefits of long-term medical therapy versus surgery. The most common side effects include inadequate control of heat burns, dysphagia, and inability to vomit. Endoscopic therapies are also being developed as possible remedy for GORD however, many controlled trials have been withdrawn due to poor efficacy and severe complications. 4. What is the incidence in Australia (last 5 yrs) of GORD? Reflux disease is common and between 15-20% of adults experience heartburn at least once a week. 5. What lifestyle modifications effect treatment of oesophagitis? What is the quality of the evidence? Losing weight (exercise) – to decrease abdominal pressure Reducing alcohol intake – once alcohol enters the blood stream it can cross the BBB and reduce nervous stimulation. Consequently, the vagus nerve that innervates the pyloric sphincter becomes dysfunctional thereby causing reflux Quitting smoking or NTR Having a low-fat diet: so that less acid will be produced. 6. If Mr. Thorpe ends up in hospital with a GIT bleed, what is the current recommended management of gastrointestinal bleeding? A GIT bleed occurs due to tearing of any part of the GIT causing blood to seep through. The clinical manifestations therefore are varied according to the site of the bleed. The patient may vomit blood due to a stomach bleed (can manifest as black due to digestion of RBC or red); may have black stools (due to digested RBC mixing with stool mass); or red residue upon wiping the anus or red blood after evacuation (due to tearing in the anus). The history can allude to the type of bleed. In T’s case, he has been drinking alcohol which can result in oesophageal varices (a consequence of chronic alcohol intake which damages the liver causing fibrosis. Consequently, this raises the pressure to the portal vein and causes it to protrude into the oesophagus -- which is damaged by acid reflux). The use of NSAIDs and gastric/duodenal ulcer can also allude to the type of bleed and its possible location. Management also involves resuscitation with patient-matching blood in order to aim for a systolic blood pressure of 100mmHg. Thiamine replacement for alcoholics (alcohol can inhibit absorption of vitamin B12) should be given (thiamine is a precursor for RBC synthesis). The next step is to organise an endoscopy especially for severe bleeds. If a rupturing ulcer is found, then adrenaline and thermal coagulation can be given via endoscopy. Adrenaline can constrict the blood vessel and coagulation can form a platelet plug clot. Haemostasis is impaired in an active bleed from an ulcer because of the fibrinolytic activity of the acidic mucosa. In this case, it is best to administer 80 mg omeprazole (or any other PPI) intravenously for 72 hours in order to give the ulcer time to heal and to stop bleeding. By contrast, uncontrolled bleeding into a non-acidic environment (in the case of oesophageal varices) cannot be controlled by a PPI so it is necessary to administer somatostatin and vasopressin (this constricts variceal blood vessels resulting in haemostasis). Management also includes prevention of a recurrent GIT bleed. If the bleed was caused by an ulcer, then consider if the patient was taking NSAIDs. This must be stopped. If the patient smoked, this must also be stopped. If indicated, the patient should be tested for H. pylori. PPI or H2 antagonist treatment for 6 weeks can be used to heal the NSAID-induced ulcer. Triple therapy (PAC500 or PAC 250) should be administered for 7 days for H. pylori eradication; then 6 weeks on a PPI or H2 antagonist for healing the ulcer. A PPI/H2 antagonist for 6-8 weeks should be given if the cause of the ulcer is not apparent. If the bleed was caused by oesophageal varices, then endoscopic treatment for 3-4 sessions with an additional therapy of banding/sclerotherapy may be considered. In addition, reduction of portal pressure can slow the rate of bleeding. Use a beta-blocker or isosorbate nitrate to dilate the blood vessel to slow the rate of bleeding and give platelets enough time to form a clot. The beta-blocker can also slow the heart rate down (because it will be beating fast to accommodate for the loss in blood pressure due to the bleed). 7. Identify a step-wise management plan for the treatment of Mr Thorpe’s GORD. Progressing from minor to major interventions and refer to your information source and its evidence. Ian could lose some weight so that there would be less pressure exerted on his stomach so that he does not experience reflux associated with weight. To lose weight, he should exercise. This will benefit him in everything, especially in preventing cardiovascular diseases (of which he is at a high risk because he is overweight and consumes too much alcohol). He should also restrict his portion sizes as well as portion content (not too much fat as the stomach compensates by producing too much acid to break it down), including meal times (at least 2-3 hours before lying down activities). He should also cut down on his alcohol intake (2-3 standard drinks per day) as this can decrease the lower-oesophageal sphincter’s ability to close properly (thus causing reflux). The evidence for this is pretty weak. For symptomatic relief, Ian could try an antacid. They work by neutralising stomach acids and thus relieving the irritation (or heartburn) that occurs when acid damages the oesophagus. Antacids should be used on a required basis only. A major step is for Ian to have an endoscopy to establish the cause of his gastric symptoms. He describes gastric symptoms which may be anything – from heartburn to abdominal pain. It is thus important to investigate the cause of his symptoms via endoscopy. If there is an ulcer-legion in the stomach or duodenum then confirmatory diagnosis should be made (stool culture, urea breath test, and serology). If H. pylori is suspected, he should be started on PAC500 (or PAC250 if he’s allergic to penicillin) for 1 month. Then he should be observed to assess whether the symptoms are still apparent. If they are, progress to a H2 antagonist for 1 month. If H. pylori is not found to be the cause of his symptoms, then he is often described as having endoscopy-negative reflux disease. There is no evidence that H. pylori should be investigated in patients with GORD. He should be on a PPI for 1 month, if there is no response, then he should be given an H2 antagonist for 4-8 weeks. He should be put on a low dose to manage symptoms. If endoscopy reveals that he has oesophagits, then he should start on a PPI for 4-8 weeks. If there is no response, the dose should be doubled. And if there is still no response, then an H2 antagonist can be given for 4-6 weeks. He should be reviewed and referred to a specialist. His treatment can be continuous for another period of time. He should be kept on the lowest dose possible (or take the meds on a required basis) that affords him symptomatic relief (probably for the rest of his life). The evidence is pretty strong for the healing of oesophagitis for PPI but not for H2 antagonists. Read More