CHAPTER

8 Monitoring Drug
Therapies
LEARNING OBJECTIVES

• Identify the skills needed to monitor • Given specific monitoring

patient drug therapy. parameters, organize patient data
• List and describe each step in the appropriately.
monitoring process.
• Identify the four types of
monitoring data included in the
four-square monitoring method.

P atient-focused care is a continuous

cycle of data acquisition and
assessment, problem identification and
the community pharmacy setting currently
is limited but is expected to increase as
access to patient databases expands with
prioritization, therapeutic planning, and advances in technology. In the not too
patient monitoring (Figure 8-1). distant future, patients may carry their
Monitoring, an important component of the complete records on small computer chips
SOAP (Subjective, Objective, Assessment, embedded on credit card–sized plastic cards
Plan)–based planning process (Box 8-1), accessible by all health care professionals
consists of identifying, measuring, and in all patient care settings.
assessing patient-specific outcome All pharmacists, regardless of the patient
parameters. Monitoring specific patient care setting or available technology, can
outcomes provides clinicians with the obtain a significant amount of monitoring
information needed to determine whether data through direct patient questioning and
the nondrug and drug interventions achieve close observation of the patient. Routine
the goals of therapy or whether the physical examination procedures such as
interventions need to be changed. measurement of blood pressure, heart rate,
Monitoring also provides the data for and respiratory rate; assessment of lung
justifying and documenting why change is sounds; and foot examination for diabetic
necessary (e.g., inadequate response, patients are already being performed in
disease progression, patient dissatisfaction, some community pharmacies as part of
drug allergy, drug interactions, or medication therapy management (MTM)
undesirable or potentially dangerous practices. Some pharmacists perform more
adverse drug reactions). comprehensive physical examinations (e.g.,
Expertise in a variety of skills (e.g., neurologic examination, funduscopic
communication skills, physical assessment examination) as they monitor more
skills) and excellent pharmacotherapy and complex therapeutic regimens. Data from
human disease knowledge are required to these routine assessments provide
monitor patients. Pharmacists in important patient monitoring information
institutional patient care facilities such as with minimal equipment or patient
acute care hospitals or long-term care invasiveness.
facilities have multiple opportunities to The amount of available patient data can
interact with patients and have access to be extensive. For example, ambulatory
extensive patient-specific laboratory and patients may self-monitor blood pressure,
diagnostic data. Pharmacists in community blood glucose, or peak expiratory flow rate
pharmacy settings such as community several times a day. In some acute patient
pharmacies or outpatient clinics interact care settings (e.g., intensive care units), the
with patients through multiple but brief patient’s blood pressure, heart rate,
patient encounters over prolonged periods respiratory rate, arterial oxygen saturation,
of time. Access to objective patient data in and electrical activity of the heart are
146 Clinical Skills for Pharmacists: A Patient-Focused Approach

monitored continuously. It is impossible to regimen provides a stable and predictable

collect, organize, and assess such large therapeutic response.
quantities of data. Fortunately, monitoring is The monitoring plan includes the
a selective, targeted process; it is not monitoring intervals for each monitoring
necessary to obtain and assess every possible parameter. Monitoring intervals depend on
piece of patient data. Monitoring consists of what the specific target outcome is and how
selecting and assessing specific data related quickly or slowly the target outcome is
to selected target outcomes. This chapter expected to be achieved; what the
introduces a structured process and approach pharmacokinetic properties (absorption,
to monitoring patient response to drug distribution, metabolism, elimination) of the
therapy. medication are; and how long it takes for a
potential adverse drug effect to appear. For
example, the level of glycosylated
PROCESS hemoglobin (Hb A1C) changes slowly in
response to long-term glucose control and is
Monitoring is an organized, structured, and routinely monitored every 6 to 12 months. It
dynamic process (Box 8-2). The initial may take several weeks for changes
monitoring plan, developed when the initial associated with pneumonia to resolve;
nondrug and drug intervention plan is repeating chest radiography within a few
created, is repeatedly revised according to days of starting a course of antibiotics is not
patient response and subsequent changes in appropriate unless the patient has signs and
the intervention symptoms consistent with progressive
pneumonia. Drug-associated anaphylaxis
145 typically occurs within minutes to hours of
Patient-Focused Care the first dose; ambulatory patients may be
Cycle observed closely for a few hours after
Data acquisition receiving the first dose then sent home with
and assessment
instructions to contact the prescriber if
symptoms develop. Isoniazid-associated
Patient hepatotoxicity
Problem identification develops slowly with
monitoring continued exposure to the drug; liver function
and prioritization
tests are performed before starting therapy to
Therapeutic obtain a baseline and then repeated monthly
planning during the 6-month course of therapy.
Chemotherapyassociated neutropenia occurs
Figure 8-1 Patient-Focused Care Cycle.
quickly and predictably; the complete blood
Box 8-1 The SOAP-Based Planning Process count and differential are monitored daily to
identify if and when preventive interventions
1. Identify the problems
(i.e., isolation, antibiotic prophylaxis) are
2. Prioritize the problems indicated. It
3. Select patient-specific drug and nondrug
Box 8-2 The Monitoring Process
interventions 4. Develop a monitoring plan
SOAP, Subjective, Objective, Assessment, Plan. Step 1—Determine specific monitoring parameters
• Select specific target outcomes
• Select monitoring intervals for each parameter
plan. For example, patients who begin Step 2—Integrate the monitoring plan
antihypertensive drug therapy initially
Step 3—Obtain data
require frequent monitoring (i.e., every 2 to 4
Step 4—Assess the response to therapy
weeks) to assess the response to the drug
takes about 10 days for phenytoin to reach
therapy. The drug dose often needs to be
steady state after therapy is initiated or the
titrated up or other medications need to be
dose is changed; non– steady-state drug
added to the regimen to achieve the target
serum concentrations may be misleadingly
blood pressure. Once the target blood
low and should not be used as the basis for
pressure is achieved and the patient’s
routine dosage adjustments. When
condition is stable, the frequency of
developing the monitoring plan, consider
monitoring can be extended (i.e., every 6 to
how long it takes for the expected
12 months). Patients who begin oral
therapeutic response to appear and the time
anticoagulation therapy initially require
course for the development of adverse drug
weekly monitoring; the monitoring intervals
effects. Some adverse drug effects are
are extended once the patient’s therapeutic
idiosyncratic and appear without warning;
 Chapter 8 Monitoring Drug Therapies 147

patients need to report any new or unusual

Subjective- Objective-Therapeutic
effects.
Therapeutic
The monitoring plan must be thorough
and complete, yet practical given the patient
setting and relative risks and benefits of the
intervention. It is not possible to monitor
for every adverse effect documented for
every drug; many clinicians monitor
patients closely for adverse effects that are
reported to occur at a rate of 10% or higher
or are less common but potentially life-
threatening. For example, monitoring for
rare potential adverse drug effects
identifiable only on the electrocardiogram
is reasonable for a critically ill patient
already undergoing continuous
electrocardiographic monitoring but not a
viable option for an ambulatory patient with
no signs or symptoms of drug-associated
cardiotoxicity. However, documenting the
baseline electrocardiographic findings and
then periodically recording an
electrocardiogram is a reasonable approach
for drugs with known but uncommon
potentially serious cardiovascular toxicities.
It is also not possible to specifically
monitor for idiosyncratic or previously
unidentified adverse drug effects. The
pharmacist must be aware of the possibility
of these types of potential adverse drug
effects and solicit and assess all patient
complaints (e.g., ask the patient if he or she
has experienced anything unusual since
starting the medication).

STEP 1—DETERMINE SPECIFIC

MONITORING PARAMETERS

All medication regimens have two possible

outcomes:
1. The medication regimen provides the
expected therapeutic benefit for the
patient.
2. The medication regimen does not
provide the expected therapeutic benefit
or is otherwise harmful to the patient.
Each outcome is assessed by questioning
the patient to elicit subjective data and by
obtaining quantifiable objective data, so
that four distinct types of monitoring data
can be collected:
1. Subjective-therapeutic—subjective data
for assessing whether the medication
regimen provides the expected
therapeutic outcome
2. Subjective-toxic—subjective data for
assessing whether the medication
regimen does not provide the expected
148 Clinical Skills for Pharmacists: A Patient-Focused Approach

Subjective-Therapeutic Monitoring
Subjective-Toxic Objective-Toxic
Parameters
Consider the patient’s symptoms and
determine the expected outcome if the drug
therapy is successful (e.g., decreased pain,
increased exercise tolerance, less shortness
of breath with exertion). If the intervention
Figure 8-2 Organization of Monitoring
produces the expected target response, the
Parameters (the Four-Square Method).
abnormalities will return to normal or at
Subjective-therapeutic monitoring parameters
are subjective measures indicating that the least approach acceptable outcomes.
expected therapeutic outcome has occurred.
Subjective-Toxic Monitoring Parameters
Subjective-toxic monitoring parameters are
subjective measures indicating therapeutic Patient symptoms will persist or even
failure or harm to the patient. Objective- worsen if the medication does not achieve
therapeutic monitoring parameters are the expected target outcome. Identify
objective measures indicating that the expected current patient symptoms and determine the
therapeutic outcome has occurred. Objective- outcome if the drug therapy is not
toxic monitoring parameters are objective successful (e.g., increased pain, decreased
measures indicating therapeutic failure or harm exercise tolerance, increased shortness of
to the patient. breath with exertion). If the intervention
fails to produce the expected target
response, the abnormal monitoring
therapeutic outcome or is otherwise parameters will remain abnormal.
harmful to the patient Subjective-toxic monitoring parameters
3. Objective-therapeutic—objective data also include monitoring parameters for
for assessing wheth er the medication adverse drug effects (side effects). Consider
regimen provides the expected the potential adverse effects attributed to the
therapeutic outcome specific medication and develop a list of
4. Objective-toxic—objective data for questions to ask the patient to identify the
assessing whether the medication presence of the adverse drug effects. For
regimen does not provide the expected example, theophylline irritates the stomach
therapeutic outcome or is otherwise and stimulates the heart. It would be
harmful to the patient appropriate to ask the patient if the
Visualize the four sets of monitoring theophylline irritates his or her stomach or
data as four subdivisions of a large square causes nausea and whether he or she has felt
(the four-square method) (Figure 8-2). Each a faster than usual heartbeat. The pharmacist
subdivision represents one of the four types needs to be careful to avoid questions that are
of monitoring data (i.e., subjective- leading questions or questions that confuse
therapeutic, subjective-toxic, objective- the patient. For example, not all patients get
therapeutic, and objectivetoxic); the large drowsy when taking antihistamines. A patient
square represents the complete monitoring asked repeatedly if his or her antihistamine
plan. The four-square method is used to makes the patient drowsy may think that the
create drug- specific monitoring plans (i.e., drug is not working because it does cause
one large square is completed for each drug drowsiness.
in a patient’s medication regimen) or to
create an integrated monitoring plan Objective-Therapeutic Monitoring
encompassing all the drugs in the patient’s Parameters Identify current abnormal
therapeutic regimen (i.e., data from objective data and determine the target
multiple drug-specific four-squares are response (e.g., weight loss of 1 to 2 lb/wk,
combined into one large integrated square). 15% increase in forced expiratory volume in
1 second [FEV1], decrease in heart rate to
>50 beats per minute but <80 beats/min). If
the intervention produces the expected target
response, the abnormal values will return to
normal or at least approach acceptable
outcomes.

Objective-Toxic Monitoring Parameters

Identify current abnormal objective data and
determine the outcome if the intervention
 Chapter 8 Monitoring Drug Therapies 149

does not achieve the target outcome (e.g., the Documented adverse effects and incidents
patient fails to lose the target weight or gains reported for ibuprofen include edema (3% to
weight, the FEV1 remains the same or 9%), rash (3% to 9%), epigastric pain (3%
decreases, the heart rate is ≤50 beats/min or to 9%), heartburn (3% to 9%), nausea (3%
≥80 beats/ min). If the intervention fails to to 9%), tinnitus (3% to 9%), headache (1%
produce the expected target response, the to 3%), nervousness (1% to 3%), itching
abnormal monitoring parameters will remain (1% to 3%), abdominal pain or cramps (1%
abnormal. to 3%), decreased appetite (1% to 3%),
Objective-toxic monitoring parameters constipation (1% to 3%), diarrhea (1% to
3%), flatulence (1% to 3%), and a very long
also include monitoring parameters for
list of adverse effects with a reported
adverse drug effects (side effects). Consider
incidence of less than 1%, including acute
the potential adverse effects attributed to the
renal failure, agranulocytosis, anaphylaxis,
specific medication and develop a list of aplastic anemia, gastrointestinal bleeding,
objective data that need to be obtained to hallucinations, inhibition of platelet
identify the presence of the adverse drug aggregation, abnormal liver function test
effects. The adverse effect itself is not results, leukopenia, pancreatitis,
necessarily the specific parameter that needs thrombocytopenia, and toxic epidermal
to be monitored. The pharmacist needs to necrolysis.
consider the reported adverse effects and Subjective-therapeutic monitoring
determine how to identify the adverse effect parameters: It is reasonable to expect that
should it occur. For example, the ibuprofen will reduce the pain, although
thrombocytopenia is a side effect associated it will not necessarily decrease the pain
with heparin therapy. Thrombocytopenia enough to allow the patient to sleep through
literally means “decreased platelets” and is the night. Therefore, the subjective-
not an appropriate monitoring parameter therapeutic monitoring target outcomes
because it is too imprecise a term. The include decreased pain and sleeping through
appropriate monitoring parameter is the the night. These monitoring outcomes can be
platelet count, with a count of less than assessed by asking the patient how well the
100,000 cells/mm3 indicating the adverse ibuprofen works to reduce her pain and
whether the pain is reduced enough to let
effect of thrombocytopenia. This is a specific,
her sleep through the night.
precise, and easily identified criterion
Subjective-toxic monitoring parameters:
outcome.
Failure of the ibuprofen to achieve the
When developing the monitoring plan, expected therapeutic outcome is recognized
select appropriate subjective and objective by the presence of persistent throbbing pain
monitoring parameters and record the that prevents the patient from sleeping
monitoring parameters in the appropriate through the night. These monitoring
subdivision of the large square; complete a outcomes can be assessed by asking the
four-square for each medication in the patient how well the ibuprofen works to
therapeutic regimen. This approach not only reduce her pain and whether the pain is
produces an organized and thorough reduced enough to let her sleep through the
monitoring plan but also provides a reminder night. A reasonable monitoring strategy for
of the relationships among the types of potential drug-associated adverse effects in
monitoring data and the reasons for this ambulatory patient with no other
evaluating specific parameters. Experienced medical conditions would be to ask her if the
clinicians work through this planning process ibuprofen upsets her stomach or causes
mentally; students and less experienced heartburn, nausea, ankle swelling, itching or
clinicians may find writing down each step a a rash, or ringing in the ears. Less common
useful exercise as they develop side effects such as pancreatitis would not be
comprehensive monitoring plans. routinely monitored for but would be
identified if the patient reported new
Example: Select appropriate subjective-
symptoms.
therapeutic, subjectivetoxic, objective-
Objective-therapeutic parameters: There
therapeutic, and objective-toxic monitoring
are no reasonably available objective data
parameters for a 25-year-old patient with a
for assessing the beneficial effects of
severe ankle sprain for which ibuprofen 600
ibuprofen for this patient. Daily imaging
mg every 8 hours is prescribed. The patient
studies (e.g., magnetic resonance imaging
has no other medical conditions. Her
[MRI]) might identify measurable reduction
symptoms include throbbing pain that keeps
in swelling, which might be associated with
her awake at night. Ibuprofen is approved by
less pain, but would be exceedingly
the Food and Drug Administration (FDA)
expensive and completely unjustifiable for
for the treatment of inflammatory disorders,
this patient.
including mild to moderate pain.
150 Clinical Skills for Pharmacists: A Patient-Focused Approach

Objective-toxic parameters: There are no the patient’s medical record, bedside flow
reasonably available objective data for sheets, and laboratory reports. Document
assessing the lack of benefit of ibuprofen for the data.
this patient. Most of the adverse effects Document the monitoring data in
documented for ibuprofen that are organized, easily assessable formats. Flow
identifiable with objective data occur at an sheets work well for documenting large
incidence of less than 1% and require amounts of objective data; brief sequential
invasive tests that would add significant cost notes work well for documenting subjective
to the care of the patient if routinely data. Many pharmacists prefer to create
monitored for. Thus, it would not be
their own customized monitoring forms or
reasonable to monitor the patient’s complete
computer files that provide a structured
blood count, liver function test results, or
format to organize the types of data they
serum creatinine level unless the patient was
at increased risk for, or was experiencing, routinely monitor in their practice settings.
adverse effects. Some pharmacists use institutionspecific
The patient does not require follow-up monitoring forms or computer files that
with the prescriber unless the ibuprofen have been developed and agreed on by
fails to control the pain or the patient consensus. Figures 8-3 and 8-4 are
develops any of the potential adverse drug examples of medication flow sheets, and
effects. The patient should be instructed to Figures 8-5 through 8-7 are examples of
contact the prescriber if the ibuprofen does objective data flow sheets. Some
not control the pain within a couple of days pharmacists prefer to use commercial
or if the ibuprofen upsets her stomach or if patient tracking software available via
she experiences heartburn, nausea, ankle smart phones, personal data assistants
swelling, itching or a rash, or ringing in the (PDAs), or wireless computer technologies.
ears or notices anything else unusual after Because of the increasing availability of
starting the ibuprofen. wireless Internet access and small portable
handheld computers,
STEP 2—INTEGRATE THE MONITORING SCHEDULED MEDICATIONS
PLAN Patient: ID Number: Physician:
Drug Allergies/Adverse Reactions:

Diagnosis:
No integration is required if the patient is
receiving just one medication. However,
Start Stop Medication Dose, Route,
most patients receive multiple drugs; Schedule
therefore the individual medication
monitoring plans must be integrated into
one master monitoring plan. One way to
integrate the monitoring plan is to create a
master list of subjective and objective
monitoring parameters collated from each
of the individual medication monitoring
plans, noting all the reasons for monitoring
any given parameter. For example, heart
rate may be an objective monitoring Figure 8-3 Scheduled Medications Flow Sheet.
parameter for the therapeutic and toxic
response to digoxin, the therapeutic
response to procainamide, and the toxic
response to theophylline. To monitor the
heart rate, the pharmacist needs to measure
the heart rate only once; however, the
monitoring plan documents all the reasons
why the heart rate is being monitored.

STEP 3—OBTAIN DATA

Once the monitoring plan is created,

monitor the patient’s response to therapy at
the predetermined monitoring intervals.
Interview the patient or caregiver for
subjective data. Obtain objective data from
 Chapter 8 Monitoring Drug Therapies 151

PRN MEDICATIONS
Patient: ID Number: Physician:
Drug Allergies/Adverse Reactions:

Diagnosis:

Start Stop Medication Dose, Route,

Schedule

Figure 8-4 As-Needed (PRN) Medications Flow

Sheet.

many pharmacists document all patient

monitoring data electronically.

STEP 4—ASSESS THE RESPONSE TO

THERAPY

Assess the subjective and objective data to

determine the patient’s response to therapy.
Look for isolated abnormalities as well as
trends. Recognizing trends is as important
as recognizing individual abnormalities. Figure 8-5 Laboratory Flow Sheets.
For example, a slowly decreasing serum
platelet count is as important as a single Time and Date
hypoglycemic reaction to a larger-than- Blood Pressure
Heart Rate
necessary dose of insulin. A slowly rising Cardiac Output
Cardiac Index
serum creatinine level should trigger a MAP
review for potential drug nephrotoxicity as RAP
RVP
well as consideration of all drug dosages. RVP, systolic
RVP, diastolic
There is no need to change the PAP, mean
therapeutic regimen if the medication PAP, systolic
PAP, diastolic
regimen achieves the desired outcomes. PAOP, mean
However, the therapeutic regimen must be SVR
PVR
changed if it does not achieve the desired CaO2
CvO2
therapeutic outcome or if it is associated
with intolerable or potentially dangerous
adverse effects (Box 8-3). Dosages may be Figure 8-6 Hemodynamics Flow Sheet.
increased or decreased; drugs may be
deleted or added to the regimen.
Make the appropriate changes to the
therapeutic regimen, modify the monitoring
plan, and continue the patientfocused care
cycle.

APPLICATION AND INTEGRATION

The case study on pages 9-11 illustrates the

patientfocused care cycle.
152 Clinical Skills for Pharmacists: A Patient-Focused Approach

Case Study Susceptibilities

Date Site Gram’s Stain Organism(s) Sensitive Resistant
Jack Campbell, a 69-year-old white male with a diagnosis of Subjective-toxic monitoring parameters—The patient’s
right- and left-sided congestive heart failure, complains of symptoms will not improve and may worsen if captopril
swollen feet, shortness of breath when walking more than half therapy does not provide the expected therapeutic benefit.
a block, nonproductive cough that is worse at night, and The patient also may experience a variety of annoying or
occasional leg cramps. He has gained 30 lb over the past 3 potentially harmful side effects from captopril therapy.
months and notes that all his clothes are too tight. He props Objective-therapeutic monitoring parameters—A variety of
himself up with three pillows when sleeping. The goal of laboratory and other tests are used to monitor
therapy is to improve the patient’s quality of life by improving improvement in cardiac function. Improvement in cardiac
cardiac function and controlling symptoms. His new function may not be immediately evident after initiation of
medication regimen includes digoxin (Lanoxin) 0.25 mg daily, treatment but may be noted after long-term drug
furosemide (Lasix) 40 mg daily, captopril (Capoten) 25 mg administration.
three times daily, and potassium chloride (Slow-K) 8 mEq three Objective-toxic monitoring parameters—A variety of laboratory
times daily. and other tests are used to monitor for lack of improvement
in cardiac function or potentially harmful side effects from
Digoxin Monitoring Parameters (Figure 8-8) captopril therapy.
Subjective-therapeutic monitoring parameters—The patient’s
symptoms will diminish or resolve if digoxin therapy provides Potassium Chloride Monitoring Parameters (Figure 8-11)
the expected therapeutic benefit of improved cardiac Subjective-therapeutic monitoring parameters—The patient is
function. receiving supplemental potassium to prevent hypokalemia
Subjective-toxic monitoring parameters—The patient’s resulting from the furosemide therapy. Because this is
symptoms will not improve and may worsen if digoxin therapy preventive therapy, no subjective parameters are available
does not provide the expected therapeutic benefit. The to evaluate the desired outcome of supplemental
patient also may experience a variety of annoying or potassium therapy.
potentially harmful side effects from digoxin therapy. Subjective-toxic monitoring parameters—The patient may
Objective-therapeutic monitoring parameters—A variety of develop symptoms of hypokalemia if potassium
laboratory and other tests are used to monitor supplementation is inadequate. Conversely, if potassium
improvement in cardiac function. Improved cardiac function supplementation is excessive, the patient may experience
may not be immediately evident after initiation of symptoms of hyperkalemia.
treatment but may be apparent with long-term drug Objective-therapeutic monitoring parameters—The goal of
therapy. therapy is to maintain an appropriate serum potassium level
Objective-toxic monitoring parameters—A variety of laboratory with supplemental therapy.
and other tests are used to monitor for lack of improvement Objective-toxic monitoring parameters—Objective monitoring
in cardiac function or potentially harmful side effects from parameters for supplemental potassium therapy are limited.
digoxin therapy.
Integrated Monitoring Plan
Furosemide Monitoring Parameters (Figure 8-9) The integrated subjective parameters monitoring plan is shown
Subjective-therapeutic monitoring parameters—The patient’s in Box 8-4. The integrated objective parameters monitoring
symptoms will decrease or resolve if furosemide therapy plan is shown in Box 8-5. The drugs in the therapeutic regimen
improves cardiac function by decreasing intravascular volume. are prescribed for the management of congestive heart failure.
Subjective-toxic monitoring parameters—The patient’s Therefore a great deal of duplication occurs among the
symptoms will not improve and may worsen if furosemide monitoring plans. However, the pharmacist needs to know the
therapy does not provide the expected therapeutic benefit. multiple reasons for monitoring each parameter. For example,
The patient also may experience a variety of annoying or blood pressure is an important therapeutic and toxic
Box 8-3 Guidelines for Altering Drug Therapy
potentially harmful side effects from furosemide therapy. monitoring parameter for several of the drugs in the
Objective-therapeutic monitoring parameters—A variety of • If the regimen
medication regimen.is ineffective, change the drug if:
laboratory and other tests are used to monitor improvement 1.Monitor
The patient received
the patient an adequate
frequently (e.g., trial of the
weekly) fordrug.
initial
in the fluid overload status of the patient. Some improvement 2. The to
response patient received
therapy, an adequate
then less frequentlydosage of the6drug.
(e.g., every
in cardiac function may occur as a result of diuretic therapy. 3. Theaspatient
months) adheredcondition
the patient’s to the prescribed
stabilizes.or Therecommended
patient
Objective-toxic monitoring parameters—A variety of laboratory shouldregimen.
weigh himself daily and contact the prescriber if he
and other tests are used to monitor for lack of improvement • If the regimen is associated with life-threatening side
has gained more than 1.0 to 1.5 lb. The serum potassium
in cardiac function or potentially harmful side effects from effects, discontinue the drug.
concentration and renal function should be assessed 1 to 2
furosemide therapy. • If the patient will not adhere to the prescribed or
weeksrecommended
after changingregimen
the dosebecause
of the captopril or potassium.
of unacceptable side
Captopril Monitoring Parameters (Figure 8-10) The serum digoxin concentration
effects, discontinue the drug. should be assessed 1 to 2
Subjective-therapeutic monitoring parameters—The patient’s weeks
• Ifafter changingisthe
the regimen dose and
effective but at
theleast annually
patient if thelife-
has non–
symptoms will decrease or resolve if captopril therapy patient’s conditionside
threatening is stable.
effectsTherapeutic
and is willing monitoring
to continue is an
the
provides the expected therapeutic benefit of improved drug,
ongoing minimize
process. the side
Modify effects:
the therapeutic regimen and
cardiac function. 1. Modifyplan
monitoring theaccording
dosage. to the patient’s response.
Figure 8-7 Microbiology Flow Sheet. 2. Change the drug administration time.
• If the regimen is effective and the patient has no
drugassociated side effects, continue the current
regimen.
 Chapter 8 Monitoring Drug Therapies 153

Subjective-Therapeutic Objective-Therapeutic
Subjective-Therapeutic Objective-Therapeutic
↓ Swelling of feet ↓ Heart size on CXR
↓ Swelling of feet ↓ Heart size on CXR
Looser-fitting clothing ↓ Edema on CXR
Looser-fitting clothing ↓ Edema on CXR
↓ SOB and DOE ↓ Weight
↓ SOB and DOE ↓ Weight
↑ Exercise tolerance ↑ Ejection fraction
Able to sleep with fewer ↑ Ejection fraction
Sleeps with fewer pillows Improved R-wave progression
pillows Improved R-wave progression
↓ Cough Normalization of R-S
↓ Cough Normalization of R-S
↓ T-wave inversion
↓ T-wave inversion

Subjective-Toxic Objective-Toxic
↑ Swelling of feet ↑ Heart size on CXR
Tighter-fitting clothing ↑ Edema on CXR
Subjective-Toxic Objective-Toxic
↑ SOB and DOE ↑ Weight
More problems sleeping ↓ Ejection fraction
↑ Swelling of feet ↑ Heart size↑on CXR
Cough Poor R-wave progression
Tighter-fitting clothing ↑ Edema onMuscle
CXR cramps Abnormal R-S
↑ SOB and DOE ↑ Weight Dry mouth ↑ T-wave inversion
↓ Exercise tolerance ↓ Ejection fraction
Thirst ↓ Serum potassium
More problems sleeping Poor R-wave progression
Dizziness ↑ Serum glucose
↑ Cough Abnormal R-SUpset stomach ↑ Serum uric acid
↓ Appetite ↑ T-wave inversion
Weakness ↑ Serum BUN/creatinine ratio
Nausea VPDs Palpitations ↑ Serum BUN
Vomiting Cardiac arrhythmias
Lethargy ↑ Serum creatinine
Halos around lights Serum digoxin >2 ng/ml
Confusion ↓ Blood pressure
Yellowish visual tinting ↓ Heart rate <50 BPM ↑ Heart rate
Abdominal discomfort ↓ SBP <100 mm Hg U wave or flattened T wave
Palpitations ↓ DBP <60 mm Hg
Weakness
Lethargy
Agitation or disorientation
 Subjective-Therapeutic Objective-Therapeutic Subjective-Therapeutic Objective-Therapeutic
154 Clinical Skills for↓Pharmacists:
↓ Swelling of feet A Patient-Focused Approach
Heart size on CXR
None. Serum potassium 3.5-5 mEq/L
Looser-fitting clothing ↓ Edema on CXR
↓ SOB and DOE ↓ Weight
↑ Exercise tolerance ↑ Ejection fraction
Able to sleep with fewer Improved R-wave progression
pillows Normalization of R-S
↓ Cough ↓ T-wave inversion

Subjective-Toxic Objective-Toxic
Nausea Serum potassium <3.5 mEq/L
Vomiting Flattened T wave
Subjective-Toxic Objective-Toxic
Diarrhea Widened Q-R-S complex
↑ Swelling of feet ↑ Heart size on CXR Bad taste Peaked T waves
Tighter-fitting clothing ↑ Edema on CXR Abdominal discomfort Flattened or inverted T waves
↑ SOB and DOE ↑ Weight Palpitations U waves
↓ Exercise tolerance ↓ Ejection fraction Lethargy
More problems sleeping Poor R-wave progression Weakness
Persistent dry cough Abnormal R-S Muscle cramps
Dizziness ↑ T-wave inversion
Itching Elevated temperature Figure 8-8 Digoxin Monitoring
Maculopapular or morbilli-form Eosinophilia Plan. Examples of subjective
rash Proteinuria Figure 8-9 Furosemide
Dysgeusia ↑ Serum creatinine Monitoring Plan. Examples of
↑ Serum BUN subjecand objective monitoring
↓ Blood pressure parameters for digoxin. tive and
WBC with differential objective monitoring parameters
for furosemide.

Figure 8-11 Potassium Chloride Monitoring Plan. Examples of subjective and objective monitoring
parameters for potassium chloride.

Figure 8-10 Captopril Monitoring Plan. Examples of subjective and

objective monitoring parameters for captopril. Box 8-5 Patient Case—Integrated Objective Parameters
Monitoring Plan
OBJECTIVE-THERAPEUTIC MONITORING
Box 8-4 Patient Case—Integrated Subjective Parameters PARAMETERS
Monitoring Plan ↓ Weight ≥ 1-2 lbs per week
SUBJECTIVE-THERAPEUTIC MONITORING CXR: ↓ Heart size; ↓ edema
PARAMETERS ↑ Ejection fraction ≥10%
General: Looser-fitting clothing; able to sleep with fewer ECG: Improved R-wave progression; normalization of S-
pillows R, ↓ T-wave inversion
Chest and lungs: ↓ SOB and DOE; ↑ exercise tolerance; ↓ Labs: Serum potassium 3.5-5.0 mEq/L
cough
OBJECTIVE-TOXIC MONITORING PARAMETERS
Extremities: ↓ Swelling of feet
↑ Weight ≥ 1-2 lbs per week
SUBJECTIVE-TOXIC MONITORING PARAMETERS CXR: ↑ Heart size; ↑ edema
General: Tighter-fitting clothing; more problems sleeping; ↓ Ejection fraction ≥10%
weakness; lethargy; agitation or disorientation; confusion; ECG: Poor R-wave progression; abnormal RS; ↑ T-wave
dizziness inversion; VPDs; arrhythmias; U waves or flat or inverted T
Vision: Halos around lights; yellowish visual tint Chest waves; flattened P waves; widened QRS complex; peaked
and lungs: ↑ SOB and DOE; ↓ exercise tolerance; T waves
↑ cough, persistent dry cough Serum digoxin >2 ng/mL
CV: Palpitations Vital signs: HR <50 beats/min; HR >120 breaths/min; BP
Gastrointestinal: Dry mouth; thirst; ↓ appetite; nausea; <100/60 mm Hg; T >100° F (37°C)
vomiting; abdominal discomfort; upset stomach; diarrhea; Labs: Serum potassium >5 mEq/L; serum potassium
dysgeusia <3.5 mEq/L; serum uric acid >7 mg/dL; serum glucose
Extremities: ↑ Swelling of feet; muscle cramps >180 mg/dL ; serum BUN/creatinine ratio >20:1; serum
Skin: Itching; maculopapular or morbilliform rash BUN >20 mg/dL, serum creatinine >2 mg/dL, eosinophils
>350/mm3; proteinuria; WBCs <5000/mm3
APPLICATION ACTIVITY a. Serum potassium level of 4.0 mEq/L
b. Serum potassium level of more than 5.5 mEq/L
Working individually or in groups of three or four, develop a c. Serum potassium level of less than 3.5 mEq/L
monitoring plan for the treatment of the iguana bite described in d. Serum potassium level of 3.5 to 5.5 mEq/L
the patient case in the Chapter 7 Application Activities section e. Serum potassium level of 2.0 to 3.0 mEq/L
(see page 143). Determine specific monitoring parameters for all Refer to the following information for questions 7 through 10: A
four types of monitoring data (subjective-therapeutic, subjective- patient with pneumonia is receiving an antibiotic for the
toxic, objective-therapeutic, objective-toxic). Select specific treatment of acute bronchitis. The patient’s symptoms include
target outcomes and monitoring intervals for each monitoring cough and fever. The antibiotic may cause diarrhea and
parameter. thrombocytopenia.
7. Decreased cough is what type of monitoring parameter?
a. Subjective-therapeutic
SELF-ASSESSMENT QUESTIONS b. Subjective-toxic
c. Objective-therapeutic
1. Monitoring a patient’s response to drug therapy requires
d. Objective-toxic
which of the following?
e. None of the above
a. Knowledge of pharmacotherapeutics
8. Decreased fever is what type of monitoring parameter?
b. Knowledge of pathophysiology
a. Subjective-therapeutic
c. Communication skills
b. Subjective-toxic
d. Physical assessment skills
c. Objective-therapeutic
e. All of the above
d. Objective-toxic
2. Which of the following is the first step in the monitoring
e. None of the above
process?
9. Diarrhea is what type of monitoring parameter?
a. Monitoring the response to therapy
a. Subjective-therapeutic
b. Assessing the response to therapy
b. Subjective-toxic
c. Setting therapeutic goals
c. Objective-therapeutic
d. Integrating the monitoring plan
d. Objective-toxic
e. Determining specific monitoring parameters
e. None of the above
3. Which of the following is the last step in the monitoring
10. Thrombocytopenia is what type of monitoring parameter?
process?
a. Subjective-therapeutic
a. Monitoring the response to therapy
b. Subjective-toxic
b. Assessing the response to therapy
c. Objective-therapeutic
c. Setting therapeutic goals
d. Objective-toxic
d. Integrating the monitoring plan
e. None of the above
e. Determining specific monitoring parameters
11. An ambulatory patient is started on antihypertensive drug
4. For what kind of patient is the availability of monitoring
therapy for newly diagnosed hypertension. When should the
data limited?
patient return to the clinic for assessment of his blood
a. A hospitalized, critically ill patient
pressure?
b. A patient who just started insulin therapy
a. One day
c. A patient with stable, well-controlled mild
b. Two weeks
hypertension
c. Six months
d. A patient undergoing renal dialysis
d. One year
e. A postsurgical trauma patient
e. Three years
5. For which kind of patient is the largest amount of
12. An ambulatory patient is started on oral pain medication for
monitoring data available?
a fractured arm. The patient has no other medical
a. A hospitalized, critically ill patient
conditions. The medication causes drowsiness in 40% to
b. A patient who just started insulin therapy
50% of patients who take the drug. Rare side effects (<1%)
c. A patient with stable, well-controlled mild
include thrombocytopenia, acute renal failure, and hepatitis.
hypertension
Weight gain has been reported with long-term use. Which
d. A patient undergoing renal dialysis
of the following is an appropriate monitoring parameter for
e. A postsurgical trauma patient
this patient?
6. A patient is receiving a medication associated with
a. Weight
hypokalemia (potassium reference range = 3.5 to 5.5
b. Serum creatinine level
mEq/L). Which of the following is an appropriate
c. Drowsiness
therapeutic goal when monitoring potassium replacement
d. Serum alanine aminotransferase level
therapy?
e. Platelet count
146 Clinical Skills for Pharmacists: A Patient-Focused Approach

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