Print Name Student Number 10121032

Further Information Required Source of Information

Investigations i.e. renal function (eGFR), FBC, U+E’s Undergo testing

How long are the nosebleeds happening? If over 15 minutes, emergency care needed. Patient
Is the patient taking any OTC medications i.e. NSAIDs Patient
Exact blood glucose levels? Diabetes nurse
General Pharmaceutical Needs/Problems Assessment Action Monitoring

Special Needs: (e.g. visual, learning, auditory disabilities or problems Yes

Ye Patient has previously found it Organise Mr KP to get a blister Monitor Mr KP’s adherence
with dexterity)
s difficult to remember which colour pack to make it easier to see what and ask him if he is finding it
tablets to take on what day
No tablets need to be taken as and easier to comply with a blister
when. pack
Problems: (e.g. practical supply problems)

Condition/ Aims Assessment A Action (including patient counselling points) Monitoring/

Problem P Follow up
N
Dose of To reduce Patient is over 80 years A Reduce dose of apixaban to 2.5mg BD instead of 5mg BD. Monitor for any signs of bleeding to
Apixaban too dose of age and has a body 5 mg twice daily, reduce dose to 2.5 mg twice daily in patients see if dose is appropriate. If
high appropriately weight of less than with at least two of the following characteristics: age 80 years bleeding continues, apixaban may be
based on the 61kg. and over, body-weight less than 61 kg, or serum creatinine in appropriate.
patient’s 133 micromol/litre and over. Patient is over 80 and less than
characteristic 61kg. Measure eGFR and follow up app.
s Annually
Keep
 Measure eGFR to see bleeding risk - if eGFR less than LFTs, FBC, HR
15 ml/min/1.73 m² (risk of bleeding) as Mr KP is
elderly.

Ensure patient has anti coag card

A = actual problem, P = potential problem, N = no problem

 ADR’s (in To make Patient has been having A  People taking oral anticoagulants should be advised: Follow up every couple of months:
particular, patient aware regular nosebleeds – o To seek immediate medical advice if Ask patient if they have had any of
bleeding) of and manage unclear on how long spontaneous bleeding occurs and does not stop, the side effects and remind them
any ADR’s these nose bleeds are or recurs. This includes bruising, bleeding gums, in particular to monitor for any
lasting. nosebleeds, prolonged bleeding from cuts, signs of bleeding or unusual
blood in the urine or stools, haemoptysis, bruising. Also emphasise the
subconjunctival haemorrhage, and vaginal importance of the patient letting
bleeding in a postmenopausal woman. any HCP’s know that they are taking
o To seek medical advice if they get sudden apixaban. Make sure they have
severe back pain (which may indicate their anti-coag alter card on them
spontaneous retroperitoneal bleeding). at all times.
o Not to take over-the-counter medicines such
as nonsteroidal anti-inflammatory drugs. Assess their compliance and if they
o What to do if there has been a missed dose or are taking it correctly.
if a double dose has been taken.
Ask about any sings of
Establish how long the nosebleeds are occurring for – it is thromboembolic events (e.g.
likely that these bleeds are occurring due to an overdose of symptoms of stroke.
apixaban – therefore, reduce dose and monitor for bleeding
again. If bleeds are over 10 minutes, emergency – there is no
antidote for apixaban.

A = actual problem, P = potential problem, N = no problem

 Blood glucose To ensure Patients blood glucose A - Establish the exact current blood glucose levels Monitor blood glucose regularly to
patients blood
levels levels apparently “aren’t - This is most likely down to the patients poor adherence see if improvement (HbA1c) every 3
glucose levels are
within range very good” rather than inappropriate medication therefore, months at least
(53 mmol/mol consider switching to a combined metformin and
(7.0%) – may be pioglitazone medication (15mg/850mg pioglitazone and Renal function at least twice a year
relaxed due to
metformin)
patients age to
prevent any micro - Emphasise importance of healthy lifestyle and diet. Ask patient if he is finding it easier
and - Counsel on hypoglycaemia and symptoms to look out for to take his diabetes medication
macrovascular
complications.
BP

Annual eye appointment

Adherence To ensure Adherence is hugely A - As already mentioned, suggest blister pack to make it Ask Mr KP if he is finding it easier
issues adherence of important for Apixaban easier to organise taking medication to take his medication after these
all medication and based on the - Potentially combine diabetic drugs. interventions.
to ensure patients previous - Ensure they know how and when to take their
optimum medication adherence, medication and stress importance of taking medication BP
results and some intervention is correctly.
prevention of clearly required to -
stroke. overcome this. Apixaban
has a short half-life so
missed doses could be
an issue in terms of
increasing stroke risk.
Smoking To make Mr Mr KP smokes 15 A Although it is unlikely that Mr KP will stop smoking as it is one Ask him his smoking status at every
KP aware of cigarettes per day of the only things that gives him pleasure plus his age, make FU.
the benefits increasing his stroke him aware of the benefits of maybe reducing the amount of
of stopping risk. cigarettes he has per day.
smoking.
Suggest NRT?

Y Y Y

A = actual problem, P = potential problem, N = no problem

 Legal Problems? Clinical Problems? Y Will you dispense prescription? Y
Clinical Check
of N N N
Prescription x
Comments Comments Comments

Combining metformin and pioglitazone. Dispense now as patient needs his

medication.
Overdose of apixaban.

In terms of cough:
- Chesty
- Any shortness of breath, blood in sputum, difficulty breathing, chest pain?
- Smoker which could possibly be contributing
- REFER TO GP IF COUGH HAS NOT IMPROVED IN 2 WEEKS
- Chesty cough cough syrup – make sure it is sugar free as he is a T2D

A = actual problem, P = potential problem, N = no problem