Patient Assessment in Pharmacy Practice 3rd Edition

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 Patient
Assessment
in Pharmacy
Practice
THIRD EDITION

Rhonda M. Jones, PharmD

Professor of Pharmacy Practice
Director, Office of Experiential Education
Department of Pharmacy Practice
School of Pharmacy and Health Professions
Creighton University
Omaha, Nebraska

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 Acquisitions Editor: Shannon Magee
Product Development Editor: Stephanie Roulias
Marketing Manager: Lisa Zoks
Production Project Manager: David Saltzberg
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Prepress Vendor: Absolute Service, Inc.

Third edition
Copyright © 2016 Wolters Kluwer.
Copyright © 2009 by Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2003
Lippincott Williams & Wilkins.

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or trans-
mitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or
utilized by any information storage and retrieval system without written permission from the copyright
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by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce
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9 8 7 6 5 4 3 2 1

Printed in China

Library of Congress Cataloging-in-Publication Data

Patient assessment in pharmacy practice / [edited by] Rhonda M. Jones. — Third edition.
p. ; cm.
Preceded by: Patient assessment in pharmacy practice / Rhonda M. Jones, Raylene M. Rospond. 2nd ed.
c2009.
Includes bibliographical references and index.
ISBN 978-1-4511-9165-3 (alk. paper)
I. Jones, Rhonda M., editor. II. Jones, Rhonda M. Patient assessment in pharmacy practice. Preceded by
(work):
[DNLM: 1. Pharmaceutical Services. 2. Diagnostic Techniques and Procedures. 3. Needs Assessment. 4.
Pharmacists. 5. Professional-Patient Relations. QV 737.1]
RS122.5
615’.1—dc23
2015018232

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based on healthcare professionals’ examina-
tion of each patient and consideration of, among other things, age, weight, gender, current or prior medical
conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does
not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals,
and not the publisher, are solely responsible for the use of this work including all medical judgments and for
any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional
verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and
treatment options should be made and healthcare professionals should consult a variety of sources. When
prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use,
warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly
if the medication to be administered is new, infrequently used, or has a narrow therapeutic range. To the
maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any
injury and/or damage to persons or property as a matter of products liability, negligence law or otherwise,
or from any reference to or use by any person of this work.

LWW.com

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 I dedicate this book to my husband, Mike, and
our children, Monica, Emily, and Adam.

Rh o n d a M . J o n e s

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000i-xviii_Jones_FM_final.indd vi 5/30/15 3:53 AM
 Preface

T he enthusiastic response of instructors and students

to the first two editions of Patient Assessment in
Pharmacy Practice has been exciting and rewarding. In pre-
■ Skill development activities have been added to the end
of applicable chapters that instructors can use to assist
students in learning, practicing, and demonstrating practi-
paring the third edition, the challenge has been to build on the cal patient assessment skills.
strengths of the book while updating information and adding ■ Updated pharmacy practice content, including clinical
new features. The third edition continues to be a textbook for practice guidelines, clinical skills, treatment recommenda-
pharmacy students and practitioners that presents a practi- tions, drug-induced symptoms, etc.
cal approach to assessing a patient’s health-related problems.
■ Chapter bibliographies are revised and updated to include
Over the past several years, the pharmacy practice culture has
the most pertinent clinical practice readings. Except for
been transitioning to patient-centered care and medication
classic or benchmark entries that contain important text,
therapy management rather than just focusing on the drug
illustrations, or tables, the bibliographies list publications
product. Within the patient-centered practice model, the phar-
from the past 7 years.
macist is responsible not only for delivery of the drug product
but also in managing the patient’s medication regimen and
improving health outcomes of the patient. An integral part ORGANIZATIONAL PHILOSOPHY
of patient-centered care and medication therapy management
involves patient assessment skills. Patient Assessment in Pharmacy Practice is divided in two
Unfortunately, most currently available health assessment parts. The chapters in Part I discuss global issues that are
books, which are intended primarily for medical and nursing related to assessing patients. Part I also contains chapters that
students, focus on physical examination skills. Although this is discuss health-related problems that span many body systems
an important piece of patient assessment, it is not the focus of (e.g., pain and nutrition).
pharmacy practice. Patient assessment within pharmacy prac- Part II is presented through a body system, head-to-toe
tice focuses on gathering patient-specific information, evaluat- approach, which is the most efficient and logical method
ing that information, identifying drug-related problems, and for assessing a patient and for student learning. Within each
formulating and implementing a patient care plan. Physical chapter, we use a patient symptom approach because that is
examination data plays a limited role as compared to the in- the most common way a patient assessment situation will
formation gathered through the health and medication his- present itself to the pharmacist.
tory. That is why we developed this book. Patient Assessment
in Pharmacy Practice has been written with one main goal in
mind: to provide students and practitioners with a practical
CHAPTER STRUCTURE
text that relates patient assessment skills to pharmacy practice. Each chapter in Part II has five major sections: Anatomy and
Physiology Overview, Pathology Overview, System Assess-
ment (i.e., subjective information and objective information),
NEW TO THE THIRD EDITION Application to Patient Symptoms (i.e., case studies), and Skill
Development Activities.
■ Chapter 1, Patient Assessment and the Pharmacist’s Role
in Patient-Centered Medication Management Services, ■ Anatomy and Physiology Overview: This section pro-
includes information regarding patient-centered care and vides a basic overview—not extensive—so all readers have
medication therapy management (MTM) as they relate to the same starting point. Preparatory levels may vary for
patient assessment skills. students and practitioners, so we felt that a basic, similar
■ Abnormal findings, located within the subjective and starting point was needed as a foundation for subsequent
objective sections of the body system chapters, include patient assessment discussion. For more extensive informa-
more drug-related information applicable to patient symp- tion on anatomy and physiology, the reader is referred to
toms and physical findings. specialty textbooks in these areas.
■ Patient cases at the end of each body system chapter ■ Pathology Overview: This section discusses the most com-
include an increased emphasis on drug-related problems mon disease states a pharmacist will encounter as well as
that pharmacists routinely assess. the most prevalent disease states for that particular body
vii

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 viii P refa c e

system. This is not meant to be an all-inclusive discussion assessment skills. The activities are not meant to be all-in-
of these disease states but rather a basic overview. As a clusive, and instructors are encouraged to expand accord-
large part of patient assessment entails correlating signs ing to their particular learning environment.
and symptoms with possible diseases, we felt that a basic
foundational discussion was necessary.
■ System Assessment PEDAGOGICAL FEATURES
● Subjective Information: The primary skill that a phar- Nearly all chapters include numerous pedagogical features
macist uses in nearly all practice settings is communica- that enhance the book’s mission as a practical text that
tion or, more specifically, patient interviewing to obtain applies patient assessment skills to the pharmacy practice
the health and medication history (e.g., symptoms and setting.
medication utilization). The interviewing technique
(INTERVIEW) that we use is a combination of open- ■ Boxes and Tables:
ended questions as a starting point and then closed-ended Throughout each chapter, special boxes highlight consistent
questions to elicit more specific symptom data concerning categories of information from chapter to chapter. These
the particular symptom. The goal is to provide focused include:
direction to elucidate information relative to the specific ● Signs and Symptoms: list the most common subjective
disease states/symptoms discussed. and objective findings related to the primary disease
● Objective Information: Physical examination and lab/ states discussed in that chapter
diagnostic tests are discussed as objective information. ● Drug-Induced Symptoms: list drugs that may cause signs
The physical examination is covered using a step-by-step or symptoms discussed in that chapter
approach with each technique (T E C H N I Q U E ) to
allow the novice learner to be able to easily follow the ap- ● Causes of Disease: list common non–drug-related causes
propriate procedures. Normal findings are described with of diseases
the technique and abnormalities (ABNORMALITIES ) are ● General boxes: list content material that requires empha-
highlighted as a separate section after each technique. In sis but does not fit the previous categories
addition, specific cautions ( C A U T I O N ) are high- ● Tables are also used throughout the text to highlight
lighted to emphasize particular maneuvers that are sensi- important information that may be more challeng-
tive to error or misinterpretation of results. ing for the reader/student to understand in basic text
■ Application to Patient Symptoms: This section is de- format.
signed as patient cases to illustrate a practice situation in ■ Key Terms (boldface text) for each chapter are listed im-
which pharmacists use patient assessment skills. We have mediately prior to the Anatomy and Physiology Overview.
attempted to vary the practice settings in which these These terms are defined in text directly following each term
cases occur; however, the majority are in the community as well as in the glossary at the end of the book.
environment.
Each case includes:
● Patient–pharmacist initial interaction ART
● Interview questions with patient responses To illustrate the textbook, figures have been chosen that
● Objective assessment information pertinent to the pa- will assist the reader’s understanding of the patient assess-
tient situation ment process. Specifically, photographs are used in nearly all
chapters to illustrate physical examination techniques as well
● Discussion to assist the student in analysis/evaluation of
as abnormal findings. Line drawings are used to illustrate
the subjective and objective patient data (i.e., the patient
normal anatomy and physiology.
assessment process)
● Patient care plan provides examples of documentation
that should accompany patient-centered care activi- SPECIAL INCLUSIONS/EXCLUSIONS
ties. Documentation is required for all healthcare pro-
It was a challenge to the authors to decide how to approach
fessionals. However, pharmacists are relatively new in
the physical examination techniques in this text. As previously
documenting their patient care interactions. We chose
stated, this area of pharmacy practice is frequently limited.
the SOAP note approach because it is the most common
However, the role of the pharmacist is expanding. Collabora-
method of documentation used across all healthcare
tive drug therapy management is on the rise and, thus, the
professions.
role of the pharmacist in patient care and medication therapy
● Self-assessment and critical thinking questions to assist management is growing. In addition, schools and colleges of
the student in learning important information from the pharmacy take varied approaches when teaching this material
chapter. Answers to the self-assessment questions are in their curriculum. Therefore, we chose to include physical
provided at the end of the book. examination techniques that are commonly used in practice
■ Skill Development Activities: The activities listed at the today (e.g., blood pressure measurement) as well as tech-
end of the chapter are suggested for the instructor to use niques that may be used only in specialty practices today or
possibly in a skills lab environment to assist students in may provide future practice opportunities (e.g., auscultating
learning, practicing, and demonstrating practical patient breath sounds).

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 P re face ix

INKLING EBOOK VERSION SUMMARY

Patient Assessment in Pharmacy Practice, Third Edition, in- Patient Assessment in Pharmacy Practice is a textbook that
cludes an eBook and the following resources on the Inkling assists the student in applying patient assessment skills to the
platform: pharmacy practice setting. It is the result of years of phar-
macy practice experience and teaching. Throughout the
■ Application Videos ( ), demonstrating patient consulta- manuscript preparation and book production, every effort
tion skills for common patient situations that students need has been made to develop a book that is informative, instruc-
to learn to succeed in the pharmacy practice setting tive, and practical. It is our hope that we have accomplished
■ Physical Examination Videos ( ), demonstrating approaches these goals.
to physical assessment of body systems
■ Heart and Lung Sounds audio program

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000i-xviii_Jones_FM_final.indd x 5/30/15 3:53 AM
 Acknowledgments

I t is my pleasure to recognize the many wonderful friends and colleagues who helped make
the revision of this textbook possible. For their encouragement, help, and support, I send my
gratitude.
To the pharmacy students at Creighton University, whose enthusiastic response and motivation
for learning were an inspiration. To the readers who took the time to write emails and letters of sup-
port, encouragement, and suggestions, your comments were gratefully received and were helpful.
To the reviewers who spent considerable time in reviewing the second edition, your suggestions and
ideas were critical to the changes and additions for the third edition.
To my friends and colleagues, who were a willing resource of information, constructive com-
ments, support, and encouragement. I am particularly grateful to Emily Knezevich, PharmD, BCPS,
CDE; Mikayla Spangler, PharmD, BCPS; Maryann Skrabal, PharmD, CDE; and Amy Haddad, RN,
PhD. To all the contributing authors who are listed at the beginning of each chapter, I extend my
thanks for their professional contribution to the content. To the pharmacy faculty and students who
reviewed the draft manuscripts and provided valuable feedback for revision, thank you.
To the tenacious team at Wolters Kluwer, who have the skills, expertise, and persistence to mold
our manuscript into a professional product. Their patience, assistance, and encouragement made
this book possible.
To the many patients and students with whom I have worked throughout the years—they are the
inspiration and source from which came many ideas for this book. It is my hope that future students
will apply the skills and principles of this text to enhance patient care within their future practice
environment.
Most importantly, I am grateful to my wonderful family. Their love and steadfast support and
encouragement kept me going throughout the revision process.

Rhonda M. Jones, PharmD

xi

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 Contributors

Ahmed Abdelmageed, PharmD Emily L. Knezevich, PharmD, BCPS, CDE

Associate Director of Experiential Education Associate Professor
Manchester University College of Pharmacy Department of Pharmacy Practice
Fort Wayne, Indiana School of Pharmacy and Health Professions
Creighton University
Tracy L. Brooks, PharmD Omaha, Nebraska
Assistant Professor
Department of Pharmacy Practice Jon T. Knezevich, PharmD, BCPS
Manchester University College of Pharmacy Assistant Professor and Director, Pharmacy Skills
Fort Wayne, Indiana Laboratory
Department of Pharmacy Practice
Estella M. Davis, PharmD, BCPS School of Pharmacy and Health Professions
Associate Professor Creighton University
Department of Pharmacy Practice Omaha, Nebraska
School of Pharmacy and Health Professions
Creighton University Paul L. Price, PharmD, BCPP
Omaha, Nebraska Associate Professor and Associate Dean for Academic and
Student Affairs
Ryan B. Dull, PharmD, BCPS Department of Pharmacy Practice
Assistant Professor School of Pharmacy and Health Professions
Department of Pharmacy Practice Creighton University
School of Pharmacy and Health Professions Omaha, Nebraska
Creighton University
Omaha, Nebraska Raylene M. Rospond, PharmD
Vice President and Dean
Michele A. Faulkner, PharmD Manchester University College of Pharmacy
Professor Fort Wayne, Indiana
Departments of Pharmacy Practice and Medicine
School of Pharmacy and Health Professions Maryann Z. Skrabal, PharmD, CDE
Creighton University Associate Professor and Assistant Director, Office of
Omaha, Nebraska Experiential Education
Department of Pharmacy Practice
Jennifer Henriksen, PharmD School of Pharmacy and Health Professions
Lab Experience Coordinator, Associate Professor of Creighton University
Pharmacy Practice Omaha, Nebraska
Manchester University College of Pharmacy
Fort Wayne, Indiana April N. Smith, PharmD, BCPS
Assistant Professor
Laura K. Klug, PharmD, BCPS Department of Pharmacy Practice
Assistant Professor School of Pharmacy and Health Professions
Department of Pharmacy Practice Creighton University
School of Pharmacy and Health Professions Omaha, Nebraska
Creighton University
Omaha, Nebraska

xiii

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 xiv C o nt r ib ut o r s

Mikayla L. Spangler, PharmD, BCPS Nicole D. White, PharmD, CDE

Associate Professor Assistant Professor
Department of Pharmacy Practice Department of Pharmacy Practice
School of Pharmacy and Health Professions School of Pharmacy and Health Professions
Creighton University Creighton University
Omaha, Nebraska Omaha, Nebraska

Robyn M. Teply, PharmD, MBA, BCACP Amy F. Wilson, PharmD

Assistant Professor Associate Professor and Assistant Dean for Academic Affairs
Department of Pharmacy Practice Department of Pharmacy Practice
School of Pharmacy and Health Professions School of Pharmacy and Health Professions
Creighton University Creighton University
Omaha, Nebraska Omaha, Nebraska

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