REVIEW CASE_DCFC+PPOK+DM+HT_BU ENDANG_2014

8/10/2019 REVIEW CASE_DCFC+PPOK+DM+HT_BU ENDANG_2014

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Studi Kasus SMF Ilmu

Penyakit Jantung

1


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2


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PROFIL PASIEN

3

Alasan MRS : Pasien rujukan dari RS Haji, dengan keluhan panas

sumer2, sesak, batuk berdahak selama 1 minggu.


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4


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Vital Sign/Laboratory Data

Initial/Follow up


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Vital Sign/Laboratory DataInitial/Follow up (lanjutan)


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10

Chronic parenchimal kidney diseasedisertai bilateral.

Kista ginjal kanan pole tengah Susp: batu ginjal kanan pole tengah

Pembesaran prostat

Hepar/lien/GB/pancreas/bladdertak tanpak kelainan.

Hasil USG Abdomen: 23/05/2012


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Hasil konsultasi terhadap data hasilUSG Abdomen dan data laboratorium

Kesimpulan: saat ini dibidang IPD

pasien mengalami DM II + CKD IV(GFR=21,3)

Tgl 18/05/2012

IPD

11


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Current Drug Therapy


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Time Line

(Circle actual administration times and recordappropriate medications and meals below.)


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14

J i Ob t T l


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No

Jenis ObatRegimen

Dosis

Tanggal

Nama dagang

/generik16/5 17/5 18/5 19/5 20/5 21/5 22/5 23/5 24/5

1 O2 500 cc/24 jam

2 IVFD PZ 500cc/24 jam

3 Furosemid 1 amp0 - 0

4 Ambroksol 3 x 1tab

5 Cefixime 2 x 100 mg //

6 Paracetamol 3 x 1 tab

7 Irbesartan 150 mg00

8 ISDN 3 x 5 mg

9 Bisolvon

nebule

Tiap 8 jam

10 Levemir 004 U

11 Allopurinol 3 X 100 mg 1x

10015


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16


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Treatment for

Heart Failure

17

ecommen a ons o armaco og ca rea men s


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ecommen a ons o armaco og ca rea men sindicated in Potentially all Patients with Symptomatic

(NYHA class II-IV) Systolic Heart Failure

ESC Guidelines for the

diagnosis and

treatment

of acute and chronic

heart failure 2012.

European Heart Journal

(2012)33, 1787184718


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LGORITM THER PY


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patients with symptomatic HF (NYHA class IIIV)and LV

systolic dysfunction

ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012. European Heart Journal (2012)33, 17871847

20


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Terapi HF: ARBTgl Obat Dosis Indikasi ESO Monitoring

16/5-

24/5

Irbesartan 150 mg-0-0 Menghambat sistem RAAS

sehingga menurunkan tekanan

darah. Pemberian ini

menggantikan ACE Inhibitor

yang memiliki ESO pada paru

Hiperkalemia TD, HR,

elektrolit

Data Klinik Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Tekanan darah 120/80 170/100 200/130 140/80 140/80 140/90

Nadi 60-100 x /

mnt

100 88 84 80 88 100 120 120 84

21


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Angiotensin Reseptor Blocker for HF

(Cochrane Review 2012)

22


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Pharmacokinetic Profile of ARB

23

E id B d ARB


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Evidence Based ARB

Terapi HF Di retik


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Terapi HF: DiuretikTgl Obat Dosis Indikasi Eso Monitoring

16/5-

24/5

Furosemide 40 mg-0-0 Mengurangi load

cairan akibat gagal

jantung

Hiperuricemia (40%),

Hipokalemia (14-

60%)

TD, K, edema

paru, sesak

Data Klinik Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Sesak - + -(berkurang)

- - -

Input250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc 250 cc

Output 750 cc/

3 jam

1400 cc/

24 jam

900 cc/

24 jam

600 cc/

24 jam

300 cc/

24 jam

500 cc/

24 jam

400cc/

24 jam

Defisit

/excess

Input=

ouput

25

Defisit belum dapat ditentukan karena input diketahui hanya dari volume

infus yang masuk ke tubuh pasien


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28

ISDN


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ISDNTgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

ISDN 3x5 mg Sebagai vasodilator

mekanpreload &afterload, me kan stroke

volumemenurunkan

tekanan darah pada kondisi

AHF

Hipotensi, sakit

kepala

TD

Pada tgl 17/5, pasien mengalami peningkatan tekanan darah yang

signifikanISDN digunakan sebagai vasodilator untuk mengatasi kondisi

hipertensi pada pasien dengan AHF.

Pengunaan nitrat sebaiknya dihindari pada pasien dengan TD sistolik


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Regimen Doses of Intravenous Vasodilators

ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012. European Heart Journal (2012)33, 17871847

30


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Treatment for

PPOK

31

AMBROXOL


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AMBROXOLTgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

Ambroxol 3x 30mg Mukolitik pada batuk

produktif

Gangguan GI

ringan

Produksi

dahak danfrekuensi

batuk

32

Data Klinik Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Batuk - + - - - -

Dahak - + - - - -

Sesak - + berkurang - - -

BROMHEXIN HCl


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BROMHEXIN HClTgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

Bromhexin

HCl

Tiap 8 jam

nebul

Mukolitik pada batuk

produktif

Batuk atau

bronkospasme

Batuk, Sesak,

Dahak

33

Data Klinik Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Batuk - + - - - -

Dahak - + - - - -

Sesak - + berkuran

g

- - -

CEFIXIME


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CEFIXIMETgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

Cefixime 3x1 tab Antibiotika pada PPOK Diare WBC, HR,

Suhu

34

Data Klinik Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

WBC 3,7010.1

x103/UL

11,9

x10311,9 x103

- - - -

HR 80-100 100 88 84 80 88 100 120 120 84

Suhu 36,5 - 37 37,8 37 36,4 36,5 36,7 36,3 36,5 36,6 36


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(NICE, 2010)


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Treatment forDiabetes

Mellitus

36

DETEMIR


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DETEMIRTgl Dagang/

Generik

Regimen

Dosis

Indikasi ESO Monitoring

20/5-24/5

Levemir 0-0-4 U Mengontrol glukosa darah Hipoglikemia GDA, GDP,GD2JPP

37

Data

Klinik

Nilai

Normal

Tanggal

15/5/

12

17/5/1

2

18/5/

12

19/5/1

2

20/5/1

2

21/5/

12

22/5/12 23/5/1

2

24/5/1

2

GDA 268

GDP 125

GD2JPP 125


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Jenis Insulin Berdasarkan Farmakokinetiknya

(DiPiro et al, 2008. Pharmacotherapy: A Pathophysiologic Approach, 7thEdition)38

PARACETAMOL


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PARACETAMOLTgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

Parasetamol 3x1 tab Demam Ruam kulit,

hepatotoksik(peningkatan

OT/PT)

Suhu

39

Data Klinik Nilai

Normal 16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Suhu 36,5 - 37 37,8 37 36,4 36,5 36,7 36,3 36,5 36,6 36

ALLOPURINOL


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ALLOPURINOLTgl Obat Dosis Indikasi ESO Monitoring

17/5;

24/5

Allupurinol 3x1 tab Menurunkan kadar asam

urat

Hipersensitifitas Asam urat

darah

40

Data Lab Nilai

Normal

Tanggal

16/5/12 17/5/12 18/5/12 19/5/12 20/5/12 21/5/12 22/5/12 23/5/12 24/5/12

Asam Urat 2,67,2 13,1


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Pharmacotherapeutic

Goal

Monitoring

Parameter

Desired

Endpoint

Monitoring

Frequency

Mengatasi sesakTerjadinya

sesak

Berkurangnya

sesakTiap hari

Ronchi

Tidak ada

ronchi

Mengatasi demam Suhu 36 - 37 C Tiap hari

Mengontrol tekanan

darahTD

< 140/ 90

mmHg (JNC

VIII)

Tiap hari

Mengontrol gula darah GDP< 110 mg/ dL

(AACE)3 hari sekali

GD2PP< 140 mg/ dL

(AACE)

HbA1c< 6,5 mg/ dL

(AACE)Tiap 3 bulan

Goals of the Therapy


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Pharmacotherapeutic

GoaltimMonitoring

Parameter

Desired

Endpoint

Monitoring

Frequency

Mengatasi sesak Terjadinya sesakBerkurangnya

sesakTiap hari

Ronchi Tidak adaronchi

Mengatasi demam Suhu 36 - 37 C Tiap hari

Mengontrol tekanan

darahTD

140/ 90

mmHg (JNC

VIII)

Tiap hari

Mengontrol gula darah GDP110 mg/ dL

(AACE)3 hari sekali

GD2PP140 mg/ dL

(AACE)

HbA1c6,5 mg/ dL

(AACE)

Tiap 3 bulan


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PharmacotherapeuticGoal

MonitoringParameter

DesiredEndpoint

MonitoringFrequency

Mengatasi nyeri dada Nyeri dadaBerkurangny

a nyeri dadaTiap hari

Mengatasi batukBatuk

berdahak

Tidak terjadi

batukTiap hari

Dahak dapat

keluarTiap hari

Mengontrol asam uratKadar asam

urat

2,6-7,2 mg/

dL3 kali sehari

Mengatasi infeksi Suhu 36 - 37 C Tiap hari

WBC4,5.103-

10.103/ mm3Berkala

RR 20X/ menit Tiap hari

Nadi 80-100 bpm Tiap hari


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MonitoringParameter

DesiredEndpoint

MonitoringFrequency

Mengatasi nyeri dada Nyeri dadaBerkurangnya

nyeri dadaTiap hari

Mengatasi batuk Batuk berdahakTidak terjadi

batukTiap hari

Dahak dapat

keluarTiap hari

Mengontrol asam urat Kadar asam urat 2,6-7,2 mg/ dL 3 kali sehari

Mengatasi infeksi Suhu 36 - 37 C Tiap hari

WBC4,5.103-10.103/

mm3Berkala

RR 20X/ menit Tiap hari

Nadi 80-100 bpm Tiap hari

DRUG THERAPY ASSESSMENT


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DRUG THERAPY ASSESSMENTWORKSHEET (DTAW)

Type ofproblem Assessment Presence of Drug-Related Problem Comments/Notes

Correlation

between Drug

Therapy and

Medical

Problem

Are there drug without a

medical indication ?

Are any medication

unidentified (are anyunlabeled or are any-prior

to admission clinic visit-

unknown) ?

Are there untreated

medical conditions ?

Do they require drug

therapy ?

1. A problem exists.

2. More information

is needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

1. Tidak dilakukan

kultur sputum

hingga 7 hari

pasien MRS

2. Tidak febris 17/5-24/5 namun

diberikan PCT. PCT

diberikan ketika

demam saja.

C DTAW (1)


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Cont. DTAW (1)

Type ofproblem Assessment Presence of Drug-Related Problem Comments/Notes

Appropriate

Drug Selection

What is the comparative

efficacy of the chosen

medication(s) ?

What is the relative safety

of the chosen

medication(s) ?

Has the therapy beentoilered to this individual

patient ?


2. More information

is needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

Pasien mendapatkan

Levemir pada tgl 20,

namun tidak ada data

mengenai monitoring

GDP.

T f P f D


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Type of

problem Assessment

Presence of Drug-

Related Problem Comments/Notes

Drug regimen Are the prescribed dose anddosing frequency appropriate-

within the usual therapeutic

range and/or modified for

patient factors ?

Is the route/dosage

form/mode of

administration appropriate,

considering efficacy, safety,convenience, patient

limitation, and cost ?

Are doses scheduled to

maximize

therapeutic effect and

compliance and to minimizeadverse effect, drug

interactions, and regimen

complexity ?

Is the length or course of

therapy appropriate ?


2. More informationis needed for

a determination.

3. No problem

exists or anintervention is not

needed.

Pasien mendapatkan

terapi alupurinol dosis

3 x 100 mg.berdasarkan literatur

(Ganiswara, ed 4,

P.221) alopurinol

mengalami

biotransformasi oleh

enzim xantin oksidasemenjadi aloxantin

yang waktu paruhnya

lebih panjang

daripada alupurinol,

sehingga cukup

diberikan 1 x 100 mg.

C t DTAW (2)


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Cont. DTAW (2)

Type of

problem Assessment

Presence of Drug-


1. Correlation

between Drug

Therapy and

Medical

Problem

Are there drug without a

medical indication ?

Are any medication

unidentified (are anyunlabeled or are any-prior

to admission clinic visit-

unknown) ?

Are there untreated

medical conditions ?

Do they require drug

therapy ?


2. More information

is needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

1. Tidak dilakukan

kultur sputum

hingga 7 hari

pasien MRS

2. Tidak febris 17/5-24/5 namun

diberikan PCT. PCT

diberikan ketika

demam saja.

Cont. DTAW (4)


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Cont. DTAW (4)Type of

problem Assessment

Presence of Drug-


Therapeutic

duplication

Are there any therapeutic

duplications?1. A problem exists.

2. More information

is needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

.

Drug allergy

Intolerance

Is the patient allergic to or

intolerant of any medicines

(or chemically related

medications)

currently being taken ?

Is the patient using any

method to alert health care

providers of the

allergy/intolerance (or

serious medical problem) ?

Adverse Drug

Events

Are there symptoms or

medical problems that may

be drug induced ?

What is the likelihood that

the problem is drug

related?

Cont. DTAW (5)


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Cont. DTAW (5)Type of

problem Assessment

Presence of Drug-


Interactions :

Drug-drug,

Drug-Disease

Drug-nutrient,

and

Drug-Laboratory

Test

Are there drug-drug

interactions ?

Are they clinically

significant ?

Are any medications

contraindicated(relatively

or absolutely) given patient

characteristic and

current/pass disease

states ?

Are there drug-nutrient

interactions ?

Are they clinicallysignificant ?

Are there drug-laboratory

test interactions ?

Are they clinically

significant ?


2. More information

is needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

.

Cont. DTAW (6)


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Co t. (6)

Type of

problem Assessment

Presence of Drug-


Social orRecreational

Drug Use

Is the patients current useof social drugs problematic ?

Could the sudden decrease

or discontinuation of social

drugs be related to patient

symptoms (e.g., withdrawal)?


2. More

information is

needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

.

Failure to

Receive Therapy

Has the patient failed to

receive medication due to

system error or

noncompliance?

Are there factors hindering

the achievement of

therapheutic efficacy?

Cont. DTAW (7)


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( )

Type of

problem Assessment

Presence of Drug-


Financial Impact Is the chosen medication(s)cost effective?

Does the cost of drug

therapy represent a financial

hardship for the patient ?


2. More

information is

needed for

a determination.

3. No problem

exists or an

intervention is not

needed.

.

PatientKnowledge of

Drug Therapy

Does the patient understandthe purpose of his or her

medication(s), how to take it

and the potential side effect

of therapy ?

would the patient benefit

from education

tool (e.g., writen patient

education sheets, wallet

cards and reminder

packaging) ?

DRUG THERAPY PROBLEM LIST (DTPL)


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DRUG THERAPY PROBLEM LIST (DTPL)

Date Problem Action

16/5/1218/5/12

Pasien tidak mengeluh demam. Nilaisuhu tubuh normal, tidak terlihat

meningkat.

Penggunaan parasetamol bila perlusaja

16/5/12 Pasien tidak perlu mendapatkan

cefixime, karena tidak menunjukkan

tanda SIRS (minimal 2)

Rekomendasi kepada dokter :

cefixime diberikan selama 3 hari.

Setelah 3 hari, dilakukan evaluasi

tanda2 SIRS

19/5/12 Pasien mempunyai DM tipe II, tetapi

monitoring nilai GDP, GD2JPP kurangadekuat, sehingga tidak tahu apakah gula

darah pasien sudah terkontrol dengan baik

apa belum.

Dilakukan pemantauan nilai GDP,

GD2JPP minimal 3 hari sekali(Berdasarkan guideline, berapa kali? PR

CESA). Dan dilakukan pemeriksaan

HbA1C untuk melihat kepatuhan pasien

dalam pengobatan

Cont. DTPL


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Date Problem Action

20/5/12 Pasien dari awal MRS sudah terdiagnosa DM

tipe II, tetapi baru diberikan terapi Levemir 0-

0-4U pada tanggal 20 Mei 2012. Seharusnya

dari awal diberikan terapi insulin short acting

dan Levemir harus monitoring GDP.

21/5/12 Pasien mendapatkan terapi alupurinol dosis 3

x 100 mg. berdasarkan literatur (Ganiswara,

ed 4, P.221) alopurinol mengalami

biotransformasi oleh enzim xantin oksidase

menjadi aloxantin yang waktu paruhnya lebih

panjang daripada alupurinol, sehingga cukup

diberikan 1 x sehari.


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Pharmacists Care Plan

Pharmacotherapeutic

Goal

Monitoring

Parameter

Desired

Endpoint

Monitoring

Frequency

Date/ TimeMei

16 17 18 19 20

Mengatasi sesakTerjadinya

sesak

Berkurangnya

sesakTiap hari Sesak

Ronchi

Tidak ada

ronchi +/+

Mengatasi demam Suhu 36 - 37 C Tiap hari 37,8 C 37 C 36,4 C 36,5 C36,7 C

Mengontrol tekanan

darahTD

140/ 90

mmHg (JNC

VIII)

Tiap hari170/

100

200/

130

Mengontrol gula darahGDP 110 mg/ dL

(AACE)3 hari sekali

125 mg/

dL

GD2PP 140 mg/ dL

(AACE)

123 mg/

dL

HbA1c 6,5 mg/ dL

(AACE)Tiap 3 bulan


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Cont. PCP (1)


MonitoringParameter

DesiredEndpoint

MonitoringFrequency

Date/ Time

Mei

21 22 23 24

Mengatasi sesak Terjadinya sesakBerkurangnya

sesakTiap hari

Sesak

berkurang

Ronchi Tidak ada ronchi -/- +/+ +/+ -/-

Mengatasi demam Suhu 36 - 37 C Tiap hari 36,3 C 36,5 C 36,6 C 36 C

Mengontrol tekanan

darahTD

< 40/ 90 mmHg

(JNC VIII)Tiap hari 140/ 80 140/ 80 140/ 90

Mengontrol gula darahGDP < 110 mg/ dL(AACE)

3 hari sekali

GD2PP


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Cont. PCP (2)


MonitoringParameter

DesiredEndpoint

MonitoringFrequency

Date/ Time

Mei

16 17 18 19 20

Mengatasi nyeri dada Nyeri dadaBerkurangnya

nyeri dadaTiap hari -

Mengatasi batukBatuk

berdahak

Tidak terjadi

batuk

Tiap hari Batuk

Dahak dapat

keluarTiap hari Dahak

Mengontrol asam uratKadar asam

urat

4,5-8,5 mg/ dL

(Pagana &

Pagana)

3 kali

sehari13,1

Mengatasi infeksi Suhu 36 - 37 C Tiap hari 37,8 C 37 C 36,4 C 36,5 C 36,7 C

WBC4,5.103-

10.103/ mm3Berkala

11,9.103

/ mm3

11,9.103

/ mm3

RR 20X/ menit Tiap hari 18

Nadi 80-100 bpm Tiap hari 100 88 84 80 88


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Pharmacist Care Plan Monitoring


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Pharmacist Care Plan Monitoring

Worksheet

Hyperlink
http://d/%E2%80%A0mfk%202013%E2%80%A0/MFK%202013/Semester%202/PEMBEKALAN%20IFRS/BU%20ENDANG/Kompilasi%20Tugas%20Kelompok%202/TUGAS%20MODUL%205/Modul%205%20KIE%20kel%20ganjil%20MFK.dochttp://d/%E2%80%A0mfk%202013%E2%80%A0/MFK%202013/Semester%202/PEMBEKALAN%20IFRS/BU%20ENDANG/Kompilasi%20Tugas%20Kelompok%202/TUGAS%20MODUL%205/Modul%205%20KIE%20kel%20ganjil%20MFK.doc

REVIEW CASE_DCFC+PPOK+DM+HT_BU ENDANG_2014

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