Mrs. Waters
Mrs. Waters is an 87 year old woman in the Ambulatory area of your department. She was sent in by the lab because she has a K+ = 5.5 on a routine blood test.
- No ECG change; feels well; normal physical exam.
- PMHx: CAD, Htn, Chol, CRF (Cr 132), anemia, GERD, mild cognitive impairment, previous CVA, chronic leg edema
- Meds: Lisinopril, Lasix, Isosorbide, ASA, Pantoprazole
- What would you do in this situation?
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Two weeks later
Mrs. Waters presents to ED in respiratory distress:
- HR104, RR 22, BP 174/96, SaO2 90%
- Exam:
- bilateral crackles
- peripheral edema
- CXR:
- CHF w/ bilateral effusions
- female chest X-ray with pulmonary edema
- ECG: sinus tachycardia
- Troponin: 290 consistent with NSTEMI
- What do you think happened?
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Important Note
Careful communication about changes to medication is important in all patients — but especially the older patient, potentially with some cognitive impairment, and multiple providers.
Discussion: Mrs. Waters
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blister pac medications
use after visit summar to highlight changes to meds and ensure caregiver also aware – hav ept and cargiver repeat back the changes and show you the medication that is changing
Y
– fax the prescription to the pharmacy
– ensure that a third party is present
– have the patient repeat the changes to evaluate the comprehension
Open and closed ended questioning of patient and caregiver
Pharmacist consult to adjust medications
Written instructions to patient and info sent to primary pharmacy and PCP
Provide written instructions to patient and a caregiver.
Communicate medication changes to primary healthcare provider and also schedule appropriate follow up with her physician soon after I discharge
agree
Written med list and discuss with fam
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ask about urine output, ask about what meds she did and did not take, ensure to determine if she stopped or halved or otherwise adjusted meds as instructed to see if this was from a med error or if something else coincidentally happened
ASKING PATIENT OR RELATIVE ABOUT ADHERENT OF MEDICATIONS
involve a third party in the help for taking medication
Involucraría a familiares, comité de fármaco terapia para brindar una educación y posibles estrategias para el control de los fármacos y la importancia de su adherencia.
La comunicación médico paciente y principalmente buscando redes de apoyo que le faciliten las indicaciones sería lo mejor
en estos casos de un adulto mayor enfermo con posible deterioro en los próximos días ,lo idea es explicar bien la situación actual y lo agudo que tiene así como la necesidad e importancia de la buena adherencia de su tratamiento crónico para buena evolución del mismo , inclusive se les puede ayudar brindando tablas con los horarios de sus medicamentos
Comunicación medico-paciente hará la diferencia entre obtener buenos resultados o que todo surja mal.
en estos casos de un adulto mayor enfermo con posible deterioro en los próximos días ,lo idea es explicar bien la situación actual y lo agudo que tiene así como la necesidad e importancia de la buena adherencia de su tratamiento crónico para buena evolución del mismo , inclusive se les puede ayudar brindando tablas con los horarios de sus medicamentos
Escribir claramente los cambios realizados
Explicar a pte y familiar sobre efectos adversos y signos de alarma
Ser enfático en la importancia de no hacer cambios por decisión propia en los fármacos usados.
My suggestion is that with changing her medication, patient should have been asked to have a review with her GP and a referral should’ve been written to inform of changes in lab value and change of medication.
It should’ve also been explained to patient which drug should be stopped. Most patients refer to lasix as “the water pill” and maybe that should be used to remind her which ones she should take and which ones she should not.
Ensure communication to patients is clear as medication changes can have negative impacts if not communicated clearly.
Need multiple ways fo teach meds
involvement of family, inquiring about how she takes her medications and diet
speak slowly
review medication
medication hx collateral from carer, GP, local pharmacist
referral to hospital pharmacist to update webster pack
clear instructions/documentation of medication chnages on dc
update and educate carer re medication changes
Geriatric patient may show signs of intolerance of meds due to age makes more sensatibve.
Writing directions for the patient down.
write things down
write the information down.
dosset box. communicate the medication change with the family/nurses. write to gp with the change. get the pharmacist to come and review.
ok
Explain to patient that the lisinopril was likely causing her elevated K, that she should stop that med but NOT stop any others. Also explain that the lisinopril is there to control BP and protect kidney function. If she notices any chest pain, SOB, leg edema et, she should present to ER immediately for reassessment.
Careful communication about changes to medication is important in all patients — but especially the older patient, potentially with some cognitive impairment, and multiple providers.
Explain medications slowly and in simple language, confirm how much patient understands, write down the changes and give this to the patient, inform care givers and GP
okk
ok
review which medication was being discontinued with packaging as well to better inform the patient which medication to use
written discharge instructions
gp review to ensure compliance/ adherence
pharmacy review
In my own experience, I usually do three things. 1) I write a prescription – specifically stating – please discontinue lisinopril and provide that to the patient 2) If the patient has their medications with them, I show them which pill bottle to stop taking (place an X on it) 3) I speak to a family member and rely the discharge instructions to them as well – re which medication is being discontinued.
clearly outline med changes
Verify with teach back method (have Pt parrot back the Tx plan)
ask the patient after discussing the medications with her and have her mention them to you to assess understanding
Ensure the patient knows how to take their medications.
I might argue that she was better off without changing her medications, mainly because of the cognitive impairment that made her vulnerable to error (which is exactly what happened in this case) if she continued her medication, she might need close monitoring of electrolites, but in this case hiperkalemia was asymptomatic and the medication she was using was fairly justified.
Establish how much the patient understands during the consultation. If there are doubts regarding understanding, use an advocate. Mild memory impairment may be overcome by ensuring the patient has written as well as verbal instructions, but more severe impairment may require an advocate. Ensure that all physicians/HPs who regularly see the patient are informed of the medication change and reasons why, with patient’s consent.
Make sure there is clear directions and instructions that patient can follow.
close follow up, good instructions
Blister pack medications, communicate directly with pharmacy, provide written insturctions to patient and their family members
provide clear easy to understand info to NOK or family, encourage follow up in 1 week to ensure no issues with changes
comes in to the er with resp distress and in pulmonary edema and elevated troponin. She is showing evidence of a cardiac event. She needs an increase in lasix i.v. push along with a nitro drip to relieve the pulmonary edema.
reaffirm the importance to be compliant with all of her meds.
closed loop feedback from pt, call family member or care facility, remind pt that she can double check paperwork if she forgets
patient was unclear on which medication to stop and stopped the wrong one. I could see that happening. I always make sure to write down which medication to change
fluid overload. Need to add a diuretic
ok
.
ghdfh
ok
good point
Verbal and written instructions. Document on pill bottle if available.
Agreed
With the relative present,the patient is given verbal nod written instructions of medications to be used.The patient is allowed to participate in her management.The doctor assesses whether the patient understands.
GP to have made the med changes and changes should have been advised via a referral letter
ok
write all medication changes down, send copy to GP. If family/support person involved inform them of changes as well with patient permission. If able follow up with patient to ensure proper regimen used.
Utilize family if available but also ensure that the patient is giving accurate information about medications, and use and regiment
Provide clear documentation, involve others in plan, write out explicitly
written documentation, informing carer and involving them in care plan.
Written instructions.
I would show her which drug to stop instead of just telling her. If they’re different colors would be a good way to differentiate for her by telling her which color to stop instead of the name of the drug.
Maybe a care taker would be available to help with the change of meds
written instructions
clear discharge instructions
consider sending home a clearly written list of changes or if pt has her med bottles with her write on the bottle
clear verbal communication
Do not use medical jargon.
communication
clear communication and getting onto the patient’s eye level
CLEAR WRITTEN INSTRUCTIONS WITH CLOSE FOLLOW UP
provide verbal and written instructions and have patient voice back plan as she understands it. Point out how two of her medications start with L and stress which one will be stopped.
Agree
I would discuss the med changes with the patient, and give them to her in writing, as well as notify her caregivers, family, and primary care physician.
ok
Got it
provide written instructions
ditto- written instructions
written and review , or if by chance you have her drug bottles , put X on the one she is stopping, involve collateral person
;
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great
Have discussion with pt’s family/caregivers re: medication change. also consider assessing how pt’s meds are distributed, via blister pack? consider calling in medication change to pt’s pharmacy to ensure proper medication is stopped (if via blister pack). Write out instructions carefully for pt/family and communicate medication changes with pt’s GP via phone/online/etc with additional communication of pt’s ER visit. Initiate plan for follow-up bloodwork with lab to then follow-up with pt’s GP.
Involvement of the family members so that they are also aware of the changes. Ensure that changes are explained to patient, ask patient to repeat changes so you are aware that she understands teh change.
Clearly write out Med. Changes. Speak with pts family and caregivers
write out meds to pt
..
1.Write things down
2.F/u with family doctor
3. Discuss with family change (or other caretaker)
It is important to make sure the patient understands exactly what medication has been stopped and what needs to continue. Clear, preferably written instructions should be provided. If patients have a cognitive impairment changes should be communicated to a family member to prevent any confusion or misunderstanding.
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I would provide patient with clear, written instructions for any changes. When doing medication changes, I would include both names of the medication. I would also send a copy of my note or private message to patient’s PCP.
.
ok
Ensure direct communication with main GP to coordinate care
document all recommended changes
communicate these changes with nursing home where medication will be administered
ensure scripts / access to medications is possible
its important that changes in medication be carefully communicated with family members or care takers as opposed to informing elder patients with cognitive impairments. Dosage changes or other changes can be written out or properly documented to make it easier to follow or remember
Speak to the patient with her family members so that she could have a better understanding
This patient needed a full assessment as well as labs drawn to see if in heart failure. Addl Lasix probably needed
needs additional Lasix.
Give a written discharge letter, phone call to GP.
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Support person could be helpful
Explain changes and reason for change slowly and clears. Ask the patients to repeat instructions to ensure they retained instructions. Provide additional written instructions that explain the changes. Provide a clearly written new medication list that incorporates the changes, that the patient can use while learning a new routine.
Explain the reasoning for the medication changes and potential side effects and then do close follow up with the pt to see if the changes are having any effects positive or negative.
I would establish close follow up to facilitate further discussion about med changes and assess status
do complete hx/review meds/have family involved in all discussions/make sure that someone is responsible for home care
Explain what to follow if medication is changed, why is changed and what we want to achieve
written instructions
Ok
ok
ok
good point
Clear communication verbally and in writing, including taking to family or caregiver.
clear communication.
double check/ clear communication
Always read and double check medication mechanism of action/indication/effectiveness/AE and recommended meds for substitution before changing them
Written instructions on changes, confirm that someone will be able to help set up medications/understands instructions, consult for community paramedicine for follow-up or complete follow-up phone call the next day to ensure understanding and compliance with discharge instructions.
communication with cognitive impairment is tricky
Medication changes require a good understanding my the recipient. Discharge instructions should be written and oral with a “teach back” opportunity and reinforced with care providers.
Making sure that it is the Lisinopril that was stopped and not the Lasix. RE-enforced continuing the Lasix or what is commonly known as the water pill. Have family or care giver make sure she is taking the right medication. Send email or some king of close loop communication with PCP about recent ED visit and change in meds for close follow-up even with just a nurse call to the patient.
yikes
utilize family when giving information/ orders
close follow up
Patient would need to demonstrate closed feedback loop – able to name all medications and indications/dosages prior to making changes in the ER. If unable to communicate effectively, would need to engage caregiver to help with medications at home with close PCP followup. Would provide written discharge instructions but also need to show pt pill bottles if brought to the ED.
Written discharge instructions and/or contact pt’s pharmacy.
k
ok
great
confirm meds with patient or caregiver
great stuff
great pointes
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Discuss with family or caregivers recent changes in diet, health, appetite, weight, supplements, etc.
Not sure
Have her caregivers remove the discontinued medication from pill organizer.
communication is the most important thing
Pt needs close follow up in the outpatient setting
Pt needs very clear instructions and close follow up
Pt needs strict instructions on medication use and follow up
Pt needs specific instructions on medication use and follow up
Pt needs clear instructions on medication changes and follow up
Clear,concise instructions. Write them down, include support people in med changes. order in blister packs from pharmacy.
1.Include family members in the conversation when changing medications.
2. Screen for cognitive impairment in the ED.
3. Write things down for the pt so they can refer back to your instructions once they’ve left the ED/clinic.
4. Encourage them to follow up with their primary care provider soon after any changes are initiated.
Great recommendations! If we all did all of these things all the time . . . there would be almost no communication problems!
write down the instruction for the patient in big printed letters that she can read and take home “STOP LISINOPRIL”
have patient ‘repeat back’ instructions to insure her understanding, reiterate with her accompanying family
write instructions out clearly.
have patient “read back” instructions to insure understanding
repeat potassium if still high prescribe kaxalate po
give written instructions. talk with family
talk to patient and assess for LOC
Get a thorough history of patient and get a list of medications she is taking, time, dosage.
Get family involvement to make sure patient is assisted to medication compliance
great point
Write down med changes, make sure pt understands
patient should know which medications to take and that should be emphasized by her PMD – also not to stop taking meds
Have the patient “teach back” to you the information you shared with them to ensure that they have understood your instructions correctly.
speak frankly but gently and remind patient of side effects of NOT taking certain medications
Compliance packs, followup with client in a week, ensure family member or other care give present when dispensing meds with appropriate information about the meds.
good point
Have the pharmasist explain the meds
good pt teaching
good point
ask the patient to repeat the order is another way you can assure that the patient understands
clear pt teaching
Orientar al paciente el régimen de tratamiento al igual que a la familia
Include her care providers in the conversation. Print out the instructions. Communicate clearly and have the pt repeat instructions
communicate the change in medication with primary care giver and home care personnel and encourage followup with primary care giver
clear information about medication instructions, patient should be asked to re-explain
Printed discharge instructions with a clear medication reconciliation.
close follow up, med rec
Simple terms, repeat basic points often. HAve caregiver present if possible
formalize order for stop/start Rx, consultation meeting with PMD and family with the pharmacist as well as a pill guide would help
Medication changes need to be communicated to PMD and cargiver also
Her Rx need to be discussed with PMD and care giver
Her Rx’s need to be discussed with her PMD and care giver
I would talk to her regarding why she is on both lisinopril and lasix. Communicate to her PCP her resulting hyperkalemia and potential need to make some medication adjustments.
write out meds
clear instructions for pt and caregivers abt med regiment
Written instruction for patient and family may have helped. Home nursing may have been an option.
communicate with family members about the warning signs and to return promptly if noticed
note to family doctor detailing drug change and follow up. I also write on the new script which pill is discontinued for the pharmacy
Write clear discharge instructions and verify if there is homecare or family involved
write down clear instructions in paperwork
Ask if she understands
ensure that patient properly understands the instructions by having her repeat back to you exactly what medication she she is stopping and what medication she is starting. also her have repeat back exactly what medications she will continue to take as she previously was.
ensure patient can repeat back which medication to stop, if her medications are in original bottles or pill box and which one to stop, communicate with PCP and have them help follow up as well to ensure compliance, home care to help in home to reassess medications, understanding and compliance.
Good understanding from pt
provide written instructions
arrange Webster pack
handover to GP/NH
Assess comprehension, ask the patient to repeat and explain the situation
Give written instructions re medication changes to patient and family as well as family physician.
Okay
Make sure she comprehends everything and have someone (pharmacist if available) go over meds with her
interesting
full wrk up
Assess the patient’s comprehension and abilities to administer her own medications safely. Have VNA do a home assessment.
ok
Using Blister packs or having a support person to confirm medication changes would help
Both verbal and written communication
Need to write down information and present it in a format that the patient understands. If possible, patient should be encouraged to have a webster pack/blister pack of her daily medications to encourage appropriate use. Webster pack should be altered prior to discharge home if she is already has one
I don’t agree with the agressive treatment of a isolated 5.5 potassium lvl. We risk making the patient worst then better if we start insuline / D50 / calcium…
need clear instructions for med changes, should use blister pack and call pharmacy for adjustments.
Send new Rx’s and changes to pharmacy to ensure they also explain and write out the new, hopefully bubble-packed, regimen.
To ensure medication changes are clearly communicated to pharmacy as well as to client ; ideally, client would have brought her meds to the hospital, and it would have been able to take the lisonopril away so that she would not have made the incorrect correction.
verbal and written instructions
important
do an assessment on physical, psychological and social
interesting
good info here
good info
Make sure you are clear in which medications are to be stopped, and that the pt understands which ones are being stopped/satrted and why
agreed
inform the changes in his medication.
helpful
ok
Write out medications to be taken and use packaging that will help the older adult
Write out the medications for the patient. Discuss with family members or others who assist with the patient’s care. Send a new prescription/stop meds to the patient’s pharmacy.
Write down medication name
clearly written instructions about medications and involve family
ss if family involved. Enlist them to assist with medications \
Write down the exact drugs you want her to stop. Have a prescription written.
Call the pharmacy
Write down the exact drugs you want her to stop. Have a prescription written.
Call the pharmacy
Writing down medication change, speaking to family members, calling pharmacy, blister packs for meds
got it
Clear communication
access if family involved. Enlist them to assist with medications \
agree with above plans
fax change to the pharmacy
Have the patient repeat instructions. Make sure a caregiver is present or send note to residence or whomever takes care of medication administration.
Make the patient repeat what I said and tell the entourage.
Often I prescribe the suspension or arrest in medication to make it clear to the pharmacy also.
Careful communication – written instructions. Involve family and counselling them on the plan and follow up and emergent care if necessary. Asking the patient to repeat the instructions in their own words to ensure they understand what they are being told. Clear labels about which medications to discontinue/continue. Ensure the patient can read them and is not visually impaired or illiterate.
write out anything discussed, make sure family is in the loop, blister pack
Proper communication and Webster pack
Proper communication
giving proper instruction and demo about the medication changed and taking the ceased medication out of the box and showing it to her not to take.
Clear prescription
STOP ACE
START AMlopdipine
Blister pack meds
Med check with her pharmacy, and clear instructions
Blister pack, make sure there’s someone that can manage her medications, especially with new meds or med changes
Blister pack and written clear instructions.
Blister pack, write down instructions, make sure caregivers (if there are any) know.
Communication is key – written instructions important for patients with cognitive decline.
Ask the patient to repeat information, write things down, have a third party rpesent if the patient allows it
Write everything down, ask patient to repeat information, have a third party present with the patient”s permission during the discussion
I write the changes down for them as well as I have called the patient’s pharmacy in the past
elderly patients close follow-up after medication changes.
written instructions
Close communication to family.
In our ED, we do write a lot to the pharmacist on the prescription sheet… why we changed medication, what to look for and special request !
Medication regimen teaching with family members to ensure compliance. Blister packs as necessary
Written instructions and close f/u
Clear verbal communication
provide written instructions
arrange Webster pack
good communication with GP +/- relatives
label her bottles with new instructions as you discuss the disposition plan. Communicate with close family, caregivers and primary doctor today’s findings and plan before discharge.
interesting
Patient should have been given a proper medication list as one of her regular medication (lisinopril) was changed to Amlodipine
Proper instruction – which medicine to stop and which to continue
Patient has got cognitive impairment — Webster pack could be considered
Involvement of a relative
Clear simple language relayed to patient
Writing down meds on paper
Liaising with community pharmacist and GP
phone review
Medication changes so often can lead to misunderstanding. Blister packs, involve family and possibly PCP follow-up to ensure pt had med reconciliation thru their pharmacy.
Strategies to increase compliance and correct medication changes is to reinforce multiple times with patient verbally and also document for patient. Reinforce this by contacting local pharmacist and medical practitioner.
Review changes with patient and primary family member – also write down changes and what to do if unusual symptoms present
Close follow-up with the patient, teach-back method (recall changes in their medications), communicate with their family doctor, blister back all required medications.
blister pack, communicate with family MD
I agree with most of discussion. Careful assessment of cognitive function is a first and communicating effectively with primary healthcare provider.
needs to communicate with GP & also with family to help with medication management due cognitive impairment
as others have stated – need to clarify for the patient which medications you’re planning on stopping. discuss with pharmacy, blister packs, etc
written communication. Blister packs and updating family members and PCP is important.
Verbal/ written communication between MD and patient. If there is any concern/ RF’s for misinterpretation or non-compliance, communicate with family/ care givers/ pharmacist/ PCA etc.
write it down. communicate with family and send note to For
call pharmacy with changes or advise reliable caregiver if available, give written instructions
Write out not just prescription to patient for pharmacist but also write down instructions for patients to take home for better recall and compliance
The first thing I would have done is repeat the K. The most common reason I see for elevated K from a clinic is the tube sitting around too long or a difficult draw.She may have had an MI because of a lab error.
what is a “female” chest X-ray?
write down plan for patient, communicate it to family members, contact pharmacy to arrange blister packs or VON/home care for med pours.
Discuss the medications with the patient and any family/friend; have meds blister packed; write out medication changes for the patient.
Write out med changes on as an Rx and fax it to pharmacy + also give patient a copy.
Communicate with pharmacy and primary care
If I make any medication changes, I will only do one thing at a time, and I will clearly communicate (i.e. verbal and written) this with the patient, their family and primary care provider.
if the patient has his meds blister bags , we can fax the Rx with the changes to his pahramcy.
Talk to care giver or even phone them to inform re the changes in his medication.
Talk with family
Careful discussion with patient and another family member in close contact to ensure adequate understanding of her medications and dosing schedule. Discouraging patient self-medicating or changing/stopping medications independently. Suggest/recommend blister packing to help her manage her medications more effectively. Assess her for cognitive decline/impairment and ensure appropriate support measures in place, i.e. local pharmacist, home care, family members, etc.
IF she came in alone, I would make every effort to locate a next of kin. Any medications changes would be given to her in writing. Her Pharmacy should be informed in writing as well. Contact her Family Physician. Make sure there is follow up with FP after d/c.
written instruction, clear speech with simple language, family at bedside for teaching
Involving the family and arranging for multiple informational resources to be given to patient on discharge for future reference
talking eith the patient,family or caregivers.writtent info and contact/fax pharmacy
Augment verbal instructions with a written medications plan. involve family and primary care.
Review medications with patient. Was she taking medications as prescribed? Review her understanding of the changes you are offering. Get help from pharmacy, relative or trusted person.
Use teach back, to make sure patient understood the instruction
Cmmunicate with a family member who is involved and can f/u or monitor
Communicate with the family doctor
Communicate with the pharmacy e.g. I would call the pharmacy to let them know of change, the script being faxed and if patient open to it, would recommend a blister pack
Discuss changes with patient and a responsible caregiver/family member. Write it down.
Review meds with Pt. and responsible family member.
Quick intervention then solid communication
ensure follow up review meds and dosing compliance etc
review meds with patient
ensure pt understands med change, inform family or someone close to pt to assist if possible
Ensure patient is compliant with medications and that her diet is appropriate.
assure the Pt and caregivers are aware
i
This patient is in need of supervision and a series of checks and balances put in place with a clear understanding of the rationale
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good point
blister pack the medications, follow up with pharmacist and GP, copy to Gp, and get the family involved.
Better communication of the intent. Share information with family physician, pharmacist, or family member/care giver. Use daily blister pack or print off a clear list of what to take and when. So many options to ensure compliance.
What do you call unicorn dandruff?
Corn flakes!
There are simply not enough characters to answer completely in these scenarios. I always try to contact the patient’s primary physician in these situations, particularly if I know that my progress note or discharge summary will not get to him/her before seeing the patient in follow-up. We can save our patients a lot of distress and our colleagues a lot of time and our health care system a lot of money by communicating within the circle of care. Even if these patients are cognitively well, they very frequently don’t know the names of their drugs: “the little white pill”. Written instructions are helpful, as is calling the pharmacist and asking them to make a new blister pack to exclude the medication being discontinued. I almost always ask if I have permission to speak to a friend/family member as well, both to obtain collateral information and to share instructions for changes, follow-up, etc.
Clearly explain to patient what medications she needs to take. What will happen if she stops taking the medication. Make sure patient gets blister pack.
It’s important to promote a two-way discussion that allows you to check that the patient understands what you told her. After explaining to her what you want to do (for example, stop the lisinpril and see her GP about starting an alternative drug), ask her to tell you what she needs to do. Also give her these instructions in writing, and have a relative in the room while explaining. Finally, send a letter to the GP explaining what you have done and why.
clearly explain to the patient as well as the caregiver which medication to stop and also to follow up with their family care physician in my setting to a local health centre.
Pharmacy- blister pack meds
Nurse/ Dr- Med reconciliation
Family members present during conversation / follow up
communication and patient understanding is as important as being a good clinician
I would like to know what medications she is on and for how long and keep a list for her in order not to have a confusion about the dose or frequency, or in case different providers are involved.
clearly written instructions on medications and have family involvement
need written instructions and if family available, make sure to repeat instructions.
interesting
interesting case, need to set up a plan to ensure patient able to take pills, homecare or pillpacks
Need to show the patient exes toy which drug to stop taking
Communicate with family members and patient to arrange follow up with family physician to have potassium levels repeated and for adjustment of medications.
speak whit family clearly and refer to the family physician to care
speak clearly and explain to familares or caregivers
not clearly explain to the patient if the families and caregivers
history and examination with relatives and caregivers present. change in medications to be discussed with relatives who hopefully could ensure taking her medication ( correct dosage/ time etc)
Assess understanding of medication indications and use and assess any cognitive impairment that would affect proper use of medication. Assess understanding of medication change. Assess social circumstances and baseline cognitive function.
written plan on meds changes, involvement of her care givers in her meds management,and F/u plan.
Write medication list and directions for pt. Contact significant other to assist at home with medications. Notify MD of changes. Arrange home health visit if no home assistance can be located.
She needs a clear regime, like blisters packs (or supervising family).
Collaboration between client, family, pharmacist and FP
Cool.
inquire if taking meds properly
xxx
xxx
fax script to pharmacy, blister pack
write new script, clarify new meds/doses with the family and patient, offer blister package, discuss and answer questions with family.
talk to family (or caregiver) about medication changes and blister pack meds
will change her lisinopril,involve her pharmacist & F/Dr in her future Rx plan,
Blister back her meds, update her care giver/family member with changes.
Recheck her K & follow up with her F/Dr.
get a competent family member to oversee the med changes.
write a note to family MD re med change and also let a competent family member know of the change and also ask pharmacist to review the med changes with her after dispensing.
contact pharmacy, review rxs
Talking to a care giver or pharmacist
Pharmacy consult
Consider blisterpack for meds.
Ensure patient understands and if not discuss with a family member as well.
Fax rx to pharmacy, communicate with family the changes and highlight on the rx as well
On the prescription, I write which meds to start AND which ones to stop.
Interesting strategy. I don’t know many docs who do that.
Fax script to pharmacy asking them to re-do blister packs
Have homecare administer meds
Educate patient with a family member present
Family MD needs copy of chart with clear writing about the changes that occurred
Written instructions are important; communicate with any close family member/spouse/caregiver as well if possible, especially if any concern re. cognitive impairment. This is a setting where cognitive impairment (dementia/delirium) would be easily missed.
Make sure there is adequate followup and that any medication changes are communicated to a caregiver to avoid patient not understanding instructions.
housecall 3 d later to see whether she was following instructions – homecare or physician
First, I would have contacted the ordering physician. Find out what process led to the lab not contacting the ordering physician. Make sure the appropriate people are aware of the non-patient-centered nature of her needing to be sent to an E.R. I would ensure that the meds are being taken appropriately, determine if she has them with her, are they in blister packs, does she administer them herself, etc.
If the primary care physician is not available I would ask for permission to involve whoever is accompanying the patient, or contact someone to be with the patient given the cognition problem. I would provide written instructions to the patient about stopping the ACE, give her a copy of the visit chart with written note to the primary care provider, requesting that she srrange for this to be given to the family physician the next day unless there is a local communication strategy that allows me to send the information digitally to the physician.
Excellent! Clearly if you had been taking care of this patient, the outcome would have been quite different!
Bubble Packs with clear communication to pharmacy
Write out medication changes suggested and give copy to patient.
tricky – good point made