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PATIENT COUNSELING-GENERAL CONSIDERATIONS, IMPORTANT STEPS &
PROCEDURES INVOLVED
Presentation · August 2018
DOI: 10.13140/RG.2.2.17621.73441
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PURPH 405: PHARMACY PRACTICE – I
PATIENT COUNSELING – GENERAL CONSIDERATIONS, IMPORTANT STEPS & PROCEDURES INVOLVED
 The management of chronic illness needs lifestyle modifications and drug therapy for a long period. Patient understanding
regarding the illness plays a very important role in management of chronic illness. Effective patient counseling makes the
patient understand his/her illness, necessary lifestyle modifications and pharmacotherapy in a better way and thus enhance
patient compliance. The pharmacist has immense responsibility in counseling the patients with chronic illness. The counseling
pharmacist should possess adequate knowledge and should be an effective communicator, making use of the verbal and nonverbal communication skills.
 What to counsel
 A pharmacist must develop, implement and fulfil plans to monitor the patient's progress towards desired therapeutic
outcomes
 Routinely and accurately identify the amount and type of education desired / required by patients to maximize their
chances of solving or preventing their drug related problem(s).
 Routinely and accurately identify the degree of monitoring required by a patient according to the health risks posed by the
patient‘s medication, drug related problems, or disease.
 Routinely, effectively and, in consideration of the above two statements, appropriately educate patients on the following when
dispensing prescription and non-prescription drugs, when patient counseling on discharge medications or when providing
recommendations about management of specific drug related problems:
 Name and class of the drug (e.g. antibiotic, pain reliever)
 Directions for use including education about drug devices
 Special storage requirements
 Common or important drug-drug or drug -food interactions
 The reason for the drug and the intended therapeutic response and associated time frames. (It recognized that
pharmacists do not always have access to the therapeutic indication for the drug).
 Common or important side effects and associated time frames
 What the patient should do to monitor his/her therapeutic response or development of side effects
 Actions the patient should take if the intended therapeutic response is not obtained or side effects develop
 When appropriate, the actions the pharmacist will undertake to monitor the patient's progress
 INDIAN HEALTH SERVICES: ―THE THREE PRIME QUESTIONS APPROACH‖
[1]. What did the doctor tell you what the medication was for?
This question allows the pharmacist to prompt the patient to discuss the purpose of the medication in regards to what it is
supposed to do and what problems or symptoms it is supposed to help.
[2]. How did the doctor tell you to take the medication?
This question promotes discussion of how to use the medication. Concerns that can be addressed include how often the
medication should be taken, how much is to be taken and for how long, and what to do if a dose is missed.
[3]. What did the doctor tell you to expect?
This question allows the patient to discuss expectations about the medication including good and bad effects, what
precautions need to be taken, how you will know if the medication is working, and what should be done if there is a bad
reaction.
 QUESTIONS THAT PATIENTS MAY ASK:
i. What is the name of the medication?
ii. What results may be expected from taking it?
iii. How does the medication work?
iv. What time of day should I take it?
v. Are there any special instructions on how to use this medication?
vi. Does food have any effect on this medication?
vii. Do alcoholic beverages have an effect on this medication?
viii. How long should I continue taking this medication?
ix. What should I do if I miss a dose?
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PURPH 405: PHARMACY PRACTICE – I
x.
xi.
xii.
xiii.
Which side effects should I report and which ones may I disregard?
How should I store this medication?
How long should I wait before reporting if this medication does not help me?
Do I have to take special precautions with this medication in combination with any prescription medications, OTC, or herbal
products?
xiv. Is my prescription renewable and for how long of a period may it be renewed?
xv. Does this medication come in a less expensive generic form?
 WHAT WILLL BE EVALUATED IN THE PATIENT COUNSELING
Judges will evaluate and score each team on the interaction and information presented during their patient counseling session.
Participants will be expected to demonstrate efficiency in these three categories: Professional Knowledge, Communication
Skills, and the Patient Interaction.
Professional Knowledge
 Provide drug education to the patient in a manner that the patient can understand and use to benefit their therapy
 Convey accurate information concerning the patient‘s medication therapy including but not limited to: medication, indication,
dosage, form, route, duration, pertinent side effects, precautions, interactions, missed dose procedures, storage
recommendations, and specific techniques for self monitoring
 Correct any incorrect information relayed by the patient
 Recognize compliance problems and increase adherence
 Discuss any potential therapeutic problems
Communication Skills
 Display effective verbal communication skills
 Use an interactive approach to assessing and verifying patient understanding through the use of open-ended questions
 Display effective nonverbal communication
 Use language the patient will be able to understand
 Demonstrate effective counseling techniques
Patient Interaction
 Communicate to the patient why the counseling session and included information is important
 Systematically think through problems and present medication information in a logical order
 Display confidence and the ability to control and direct the counseling session
 Manage time during the session effectively
 Work efficiently with their team member
 Counseling on non-prescription drugs
 Effective non-prescription drug counselling requires a thorough description of patient's symptoms. Before advice can be given,
the postgraduate student will need knowledge on the nature, severity and extenuating circumstances surrounding those
symptoms. As well, other aspects of the patient's health e.g. other diseases, drugs, contraindications, allergies, must be
examined. This information-gathering" stage is most important.
 When non-prescription drugs are indicated, the postgraduate student must be able to give information to the patient so
products are used both safely and effectively.
 When providing care to patients involving over the counter medications, it is necessary to perform an adequate miniassessment of the client‘s problem, consisting of:
 Properly identifying the person who will be using the product and determining their approximate age;
 Inquiring about any current medical conditions;
 Asking about current non-prescription drug use, including herbal products;
 Asking about current prescription drug use;
 Inquiring about the symptoms and duration of the complaint;
 Asking about whether the client has any medication allergies; and,
 Asking whether the client has consulted a health care professional about the problem.
 You should refer the client for medical attention if:
 Their condition is potentially severe,
 They are uncertain about their symptoms,
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PURPH 405: PHARMACY PRACTICE – I
 Their self-diagnosis is likely incorrect,
 The condition has not responded to previous appropriate therapy, or
 They have other risk factors that should be assessed.
 When you have assessed the client and the problem, and feel that a referral is not necessary, you may recommend an
appropriate product or course of action, including non-drug measures. If you recommend a non-prescription drug product, you
should discuss:
 Directions for use;
 Expected outcomes of therapy, including a time-frame for a response;
 Common adverse effects and precautions;
 Correct storage; and,
 When to seek medical attention.
 Ideally, you should document nonprescription drug use on the client‘s medication profile. This is especially important for clients
who have a medical condition and/or are taking prescription medication.
 Medication Counseling Tips
 Establish relationship – show interest in patient (verbal & nonverbal)
 Verify patient's name and prescriber's name
 Why the patient is being prescribed the medication (if known) or the medication‘s use, expected benefits and action
 Open the medication containers and show patient what the medication looks like, or demonstrate use
 How to take the medication
 When to take and how long to take the medication
 What to do if a dose is missed
 Any special precautions to follow
 Foods, alcoholic beverages or OTC‘s to be avoided
 How the patient will know the medication is working
 How to store the medication
 If the prescription can be refilled, and if so, when
 Verify the patients‘ knowledge and understanding
 Ask the patient if they have any questions
 Document the interaction
 Patients who should always be counseled:
 Confused patients, and their caregivers
 Patients who are sight or hearing impaired
 Patients with poor literacy
 Patients whose profile shows a change in medications or dosing
 New patients, or those receiving a medication for the first time (transfer prescription)
 Children and parents receiving medication
 Patients receiving medication with special storage requirements, complicated directions, significant side effects.
 Patients who should be counseled at certain intervals:
 Asthmatic patients
 Diabetic patients
 Patients taking 4 or more prescribed medications
 Patients who are mentally ill
 Patients using appliances
 Epileptic patients
 Patients with skin complaints
 Patients misusing drugs
 Patients who are terminally ill
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PURPH 405: PHARMACY PRACTICE – I
DEFINITION OF A DISPENSING ERROR
 A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or
distributes to the ward on the basis of this prescription, including the dispensing of a medicine with inferior pharmaceutical or
informational quality
 Six main types of medication error can occur in the chain of pharmacological and pharmaceutical patient care:
i. Prescribing faults,
ii. Prescription errors,
iii. Transcription errors,
iv. Dispensing errors,
v. Administration errors, and
vi. ‗Across settings‘ errors
 Strategies for Minimizing Dispensing Errors
1. Ensure correct entry of the prescription.
Transcription errors (eg, omissions, inaccuracies) account for ~15% of all dispensing errors6 These errors can be reduced by
consistently using reliable methods to verify patient identity while entering the prescription into the computer. The Joint
Commission requires that at least 2 patient identifiers be used for administering medications in a hospital setting. This strategy
helps prevent medication errors due to sound-alike, look-alike names. At this point in the process, it is also useful to have
information about the patient, such as the age of the patient, allergies, concomitant medications, contraindications, therapeutic
duplications, and the like.
2. Confirm that the prescription is correct and complete.
Pharmacists‘ ―second guessing‖ of illegible and/or ambiguous prescriptions, nonstandard abbreviations, acronyms, decimals, and
call-in prescriptions are frequently associated with medication errors.6 Whenever in question, it is important to call the prescriber to
clarify any uncertainties or doubts regarding the prescription. Clarification obtained from the physician should be promptly
documented. All verbal prescriptions should be immediately transcribed to a blank prescription pad and read back to the caller to
ensure that the prescription has been transcribed correctly.
3. Beware of look-alike, soundalike drugs.
Similar drug names account for one third of medication errors. These types of errors are attributed to confirmation bias—a
tendency to interpret information in a way that confirms one‘s preconceptions and avoids information and interpretations that
contradict prior beliefs. As an example, a new, unfamiliar drug may be read as an older, more familiar one. Some of these errors
can be fatal (eg, prescribing methadone instead of methylphenidate to an 8-year-old child).8 Such errors can be reduced by placing
reminders on the stock bottle or in the computer system to alert staff about these commonly confused drug names.
4. Be careful with zeros and abbreviations.
Misplaced zeros, decimal points, and faulty units are common causes of medication errors due to misinterpretation. A transcription
or interpretation error involving a zero or a decimal point means that the patient may receive at least 10 times more medication
than indicated, which can result in serious consequences (eg, levothyroxine, warfarin). These errors may be prevented by using
computer alerts or by stocking a single strength of the medication in the pharmacy. These errors may be detected when reviewing
the label directions during patient counseling. The Institute for Safe Medication Practices (ISMP) offers a list of error-prone
abbreviations, symbols, and dose designations (a brief list of common dispensing errors is given in the Table). Being familiar with
this type of information may also help prevent dispensing errors.
5. Organize the workplace. Organizing work space, work environment, and workflow has been shown to markedly reduce
dispensing errors. Proper lighting, adequate counter space, and comfortable temperature and humidity can help facilitate a smooth
flow from one task to the next, thus reducing the chances of dispensing errors. Developing a routine for entering, filling, and
checking prescriptions will help in organizing the flow of work. In addition, working with one drug product at a time and affixing the
label to the patient‘s prescription container before working on the next prescription will help prevent mix-ups. It is also important not
to leave any drug containers unlabeled.
6. Reduce distraction when possible.
Multitasking and distraction during work is the leading cause of dispensing errors. Automatic-refill requests can reduce some of the
distractions and thereby reduce dispensing errors. Also, having pharmacy technicians assist the pharmacists by performing routine
functions will help minimize distractions. Although the extent to which distraction at work contributes to cognitive error is unclear,
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PURPH 405: PHARMACY PRACTICE – I
recent studies suggest that perception of dispensing errors by pharmacists is influenced by factors such as design of workflow,
window services, and automatic dispensing. It must therefore be the goal of each pharmacy to improve the internal environment,
even at the cost of patient convenience, in order to reduce medication errors.
7. Focus on reducing stress and balancing heavy workloads.
Workload increase is often cited as a contributing factor in dispensing errors. Sufficient staffing and appropriate workload will help
reduce errors. Regular breaks and time off for meal breaks may help reduce some of the dispensing errors. Sharing responsibilities
by clearly assigning duties to the staff will help them understand the expectations of the flow of work and may ultimately aid in
reducing workplace stress, and, therefore, reduce medication errors.
8. Take the time to store drugs properly.
One way to avoid mix-ups among lookalike drugs is to store them away from each other in the medication storage area. Medication
bottles should be properly organized with labels facing forward. It is also a good idea to routinely check all medications on the
shelves and discard any expired medications. Use of storage bins, cabinets, or drawers can result in misplacement of look-alike
drugs. It is also advisable to lock up or sequester drugs with high potential of causing errors.
9. Thoroughly check all prescriptions.
Repeated checking and counterchecking is an important strategy to minimize dispensing errors. Comparing the written prescription
with the product that appears in the computer, with the label being printed, and with the medication that is being filled will help
reduce errors. Confirmation bias and preconceived notions makes self-checking a poor method to reduce errors. Whenever
possible, it is advisable to have the rechecking done by another person, typically a pharmacist. If this is not possible, delayed selfchecking rather than continuous self-checking is an alternate strategy. A delayed verification will allow the pharmacist to study the
prescription from a fresh perspective, which will help in identifying the error that may not have caught his/her attention the first time
the prescription was handled.
10. Always provide thorough patient counseling.
Approximately 83% of errors are discovered during counseling and are corrected before the patient leaves the
pharmacy.15 Therefore, it is important to go beyond offering to counsel and provide counseling for each patient. It is considered
good practice to open the container and show the actual medication to the patient during counseling rather than deliver it to the
patient in a sealed bag. Completing this process will provide an opportunity for the patient to see the medication and ask questions
if it looks different from what he or she has been taking. Counseling should also include the instructions on how to take the
medication and appropriate route of administration. Many dispensing errors are attributed to misunderstood directions for use.
Educating patients about safe and effective use of their medication promotes patient involvement in their health care, which will
likely reduce medication errors.
The goal of every pharmacist is to minimize dispensing errors. Patient counseling being the last point of contact between the
patient, pharmacist, and medication in the dispensing process is by far the most important strategy that every pharmacist must
adopt in order to minimize dispensing errors. In addition, reporting errors as they occur and when they occur will help in learning
from the mistakes and ultimately prevent such errors in the future.
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PURPH 405: PHARMACY PRACTICE – I
 PROCEDURE TO FOLLOW IN CASE OF A DISPENSING ERROR
1. When presented with a complaint, ensure the matter is handled by the pharmacist.
2. Show concern and willingness to correct any error.
3. Check out the alleged error and if established, replace the offending item immediately. Do not charge for the replacement. If
it was dispensed at another pharmacy, check with that pharmacy and replace if possible. Take care not to compound the
problem. Retain the evidence if possible.
4. An apology couched in the correct way will not constitute an admission of liability. You should use either of the following two
examples which are ways of apologising without admitting liability: “I am sorry this has happened”; “I know this has caused
you great pain/distress/anxiety.”
5. Determine whether any of the wrong drug has been used, or medication missed. Has any harm been suffered? Has any
expense been incurred?
6. DO NOT OFFER COMPENSATION - This may be regarded as an attempt to bribe your way out of trouble.
7. DO NOT mention your insurance cover or the Pharmacy Board, as this will only sow the seeds of opportunity.
8. Show empathy with the patient. This gives them the opportunity to vent their feelings so you might learn where you truly
stand.
9. At all times remain calm, sympathetic and co-operative. Advise that you will investigate how this occurred and take action to
tighten procedures. Obtain a phone number and show an ongoing interest in the welfare of the patient.
10. Telephone PDL and report the problem. You will be advised what further action to take. It is important that you report any
incident where the wrong drug or wrong dose has been ingested, as a claim could be lodged at some future date.
11. Record the details and patient history and all relevant information in your diary.
12. These notes may be extremely important in any subsequent defence of a claim.
13. If after the patient has left the pharmacy, you suspect that an error has been made, act speedily to correct the problem,
without causing any unnecessary alarm.
14. When a complaint is initiated by correspondence it is MOST IMPORTANT that you do not reply without first asking advice
from PDL. Do not put anything in writing without advice from PDL.
15. If confronted by investigating officer seeking information relating to drugs dispensed for a patient who has died or whose
health has been compromised, it is recommended that PDL be contacted immediately so that legal advice can be provided.
16. When any incident occurs contact the prescriber as a matter of professional courtesy.
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PURPH 405: PHARMACY PRACTICE – I
 EXTRACT
An extract is a substance made by extracting a part of a raw material, often by using a solvent such as ethanol or water. Extracts
may be sold as tinctures or in powder form.
Extraction techniques
 Expression when the oil is very plentiful and easily obtained, as in lemon peel.
 Absorption is generally accomplished by steeping in alcohol, as vanilla beans.
 Maceration is used to create smaller bits of the whole, as in making peppermint extract, etc.
 Distillation is used with maceration, but in many cases, it requires expert chemical knowledge and the erection of costly stills.
 INFUSION
 In this method, the plant material (herbal tea) is placed in a pot and wetted with cold water. Immediately afterwards, boiling
water is poured over it, then left to stand covered with a lid, for about fifteen minutes after which the tea is poured off.
 The process of extracting chemical compounds or flavors from plant material in a solvent such as water, oil or alcohol, by
allowing the material to remain suspended in the solvent over time (a process often called steeping).
 A common example of an infusion is tea, Coffee can also be made through infusion
 DECOCTION
 If the plant material is boiled for ten minutes or if boiling water is poured over it and allowed to stand for thirty minutes, the
result is called decoction.
 Method of extraction by boiling, of dissolved chemicals, from herbal or plant material, which may include stems, roots, bark
and rhizomes. Decoction involves first mashing, and then boiling in water to extract oils, volatile organic compounds, and other
chemical substances. Decoction can be used to make tisanes, teas, coffees, tinctures and similar solutions. The process can
also be applied to meats and vegetables to prepare bouillon or stock.
 PERCOLATION
In this method, the ground plant material is subjected to a slow flow of fresh solvent. Percolation (from Lat. percōlāre, to filter or
trickle through) concerns the movement and filtering of fluids through porous materials
Percolator
 MACERATION
 This method is used frequently for water soluble active constituents. It consists of macerating the plant material in cold water
(15-200 C) for several hours.
 With the maceration extraction method, the flowers are soaked in hot oil to have their cell membranes ruptured and the hot oil
then absorbs the essence. The oil is then cleared of the botanical and decanted.
 SPIRITS
Spirits are alcoholic or hydroalcoholic solutions of volatile substances. Most are used as flavoring agents but a few have medicinal
value. The active ingredient in the spirit may be a solid, liquid or gas.
Use:
(i) They are mainly used as flavoring agents. e.g. Lemon spirit, Peppermint Spirit, Compound Orange Spirit etc.
(ii) Some spirits are taken internally for their medicinal value e.g. Aromatic Spirit of Ammonia IP is a respiratory stimulant.
Storage:
Spirits contains volatile substances hence, should be stored in tight containers and should be stored in a cool place. This prevents
the volatilization of alcohol or the active substances.
Methods of preparation:
(i) Simple solution method: e.g. Chloroform Spirit IP, Spirit of Ether IP
(ii) Solution with maceration: e.g. Compound Orange Spirit IP
(iii) Distillation: e.g. Aromatic Spirit of Ammonia IP
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PURPH 405: PHARMACY PRACTICE – I
 AROMATIC WATERS
Aromatic waters are clear, saturated solutions of aromatic substances (may be volatile oils or volatile solids) in water. Their flavors
and taste are similar to the corresponding aromatic substances used.
Use:
(i) They are mainly used as the vehicle for oral liquid preparations due to their flavoring properties. E.g. Peppermint Water IP.
(ii) Some aromatic waters have preservative action, hence are used as menstruum to extract crude drugs. E.g. Chloroform Water IP.
(iii) Some aromatic waters have mild therapeutic action. E.g. Camphor Water IP has carminative action, Anise Water has
carminative and mild expectorant action.
Methods of Preparations
(a) Solution method
(i) The volatile oil is shaken with 500 times its volume of Purified Water IP.
(ii) The mixture is shaken for a period of 30 minutes.
(iii) The mixture is set aside for 12 hours or overnight.
(iv) Filtered.
(b) Using distributing agents
(i) The volatile oil is triturated with a sufficient quantity of powdered talc or kieselghur, or pulped filter paper in a mortar.
(ii) Purified Water IP 500 times the volume of oil is taken and mixed.
(iii) The solution is filtered.
N.B. Talc, kieselghur, pulp of filter paper are called distributing agents. The volatile oils get adsorbed on the particle surface and a
large surface area helps in quick dissolution of the oil into water.
(c) Dilution from cnocentrated preparations
(i) A concentrated aromatic water is prepared as per the formula given in the pharmacopoeia.
(ii) One ml of concentrated aromatic water is diluted with 39 ml of Purified Water IP and mixed.
 TINCTURES
 A tincture is typically an alcoholic extract of plant or animal material or solution of such or of a lowvolatility substance (such
as iodine and mercurochrome). To qualify as an alcoholic tincture, the extract should have an ethanol percentage of at least
40–60%. In herbal medicine, alcoholic tinctures are made with various concentrations of ethanol, 25% being the most
common. Other concentrations include 45% and 90%.
 Herbal tinctures are not always made using ethanol as the solvent, though this is most commonly the case. Other solvents
include vinegar, glycerol, ether and propylene glycol, not all of which can be used for internal consumption. Ethanol has the
advantage of being an excellent solvent for both acidic and basic (alkaline) constituents.
 Glycerine can also be used, but when used in tincturing fashion is generally a poorer solvent. Vinegar, being acidic, is a better
solvent for obtaining alkaloids but a poorer solvent for acidic components. For individuals who chose not to imbibe alcohol,
non-alcoholic e,g., (glycerite) extracts offer an alternative for preparations meant to be taken internally.
 Tinctures are alcoholic or hydroalcoholic solutions usually containing dilute concentration of active principles of
vegetable or animal drugs.
 Methods of preparation: They are commonly prepared by maceration or by percolation process.
N.B. Most tinctures of vegetable drugs represent the extractive from 20g of the drug in 100ml of tincture.
Types: Aconite Tincture IP, Belladonna Tincture IP, Capsicum Tincture IP, Compound Cardamom Tincture IP, Compound
Cinchona Tincture IP, Datura Tincture IP, Digitalis Tincture IP, Strong Ginger Tincture IP, Hyoscyamus Tincture IP,
Ipecacuanha Tincture IP, Nux Vomica Tincture IP, Opium Tincture IP, Camphorated Opium Tincture IP, Orange Tincture
IP, Compound
Uses: analgesic, cardiac depressant, Parasympatholytic, Carminative, Carminative, Antimalarial, Parasympatholytic,
Cardiotonic, Carminative, Expectorant and Emetic, Bitter stomachic, Hypnotic, sedative, Flavoring Agent, Bitter
stomachic, Parasympatholytic
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PURPH 405: PHARMACY PRACTICE – I
 ELIXIRS
Elixirs are clear, liquid, oral preparations of potent drugs (like antibiotics, antihistaminics, sedatives etc.) or unpalatable drugs. They
are pleasantly flavoured and usually attractively colored.
N.B. Elixirs are clear preparations, but mixtures are often not clear due to the presence of fine droplets of volatile oils present in it.
Formulation:
Vehicles are the main part of the preparation that carries the drug.
Production of a clear solution: Flavoring agents containing essential oils or precipitates from plant extract may produce faint
cloudiness. To keep the essential oils in solution state 10 – 20% of alcohol is added. Glycerol (i.e. glycerin) is added to keep the
essential oil in to solution and to dissolve some ingredients of plant extracts like tannins and their oxidation products.
Solution of medicament of low water solubility: If the drug is not completely soluble in water then a mixed solvent is used to
dissolve the drug (i.e. medicament). E.g. phenobarbitone is dissolved in alcohol, glycerol and water, paracetamol is dissolved in
alcohol, propylene glycol and glycerol.
N.B. Alcohol is avoided in paediatric elixirs hence in paediatric Paracetamol Elixir propylene glycol is used as the main solvent.
Production of a palatable preparation: The vehicle of many elixir is syrup or a flavored syrup.
Adjuncts
Chemical Stabilizers: Some special chemicals are required to make the elixir stable. e.g. Citirc acid, disodium edetate etc.
Coloring agents: Many elixirs are attractively colored by coal tar dyes. e.g. Amaranth (magenta red), Compound Tartrazine
(saffron), Green S and Tartrazine (Green).
Flavoring agents: Sweetening agents and fruit flavors are used.
Sweetening agents: e.g. Plain and flavored sucrose syrup, glycerol, sorbitol, invert syrup and saccharin sodium.
Fruit flavor: Blackcurrant syrup (to mask bitter taste of drug), Raspberry Syrup (to mask bitter taste of drug), Compound Orange
Syrup (to mask sour and bitter taste of drugs).
Preservatives: To reduce the mould growth and fermentation preservatives are added. Vehicle containing 20%v/v alcohol,
propylene glycol or glycerol have preservative action. High concentration of syrup has high osmotic pressure thus acts as
preservative. Chloroform Water, Chloroform Spirit have preservative action. Benzoic acid, methyl parahydroxybenzoate acid
(methyl paraben) or propyl parahydroxynenzoate (propyl paraben) may be used as additional preservatives.
Example: Preparation of Piperazine Citrate Elixir IP
Formula: Piperazine citrate 180g
Chloroform Spirit 5ml
Glycerin 100ml
Orange Oil 0.25ml
Syrup 500ml
Purified water up to 1000ml
Method: Piperazine citrate is dissolved in small amount of purified water. Orange oil, glycerin, syrup and chloroform spirit is mixed.
Sufficient volume is added to produce the final volume.
Use: Anthelmintic.
 COLD CREAM
Cold cream is an emulsion of water and certain fats, usually including beeswax and various scent agents, designed to smooth skin
and remove makeup. The emulsion is of a "water in oil" type unlike the "oil in water" type emulsion of vanishing cream, so-called
because they seem to disappear when applied on skin. The name, cold cream, derives from the cooling feeling that the cream
leaves on the skin. Variations of the product have been used for nearly two-thousand years.
Cold cream is mainly used for skin treatment, due to its moisturizing properties, such as as a facial mask, lip balm, etc.
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PURPH 405: PHARMACY PRACTICE – I
 LINCTUSES
Linctuses are viscous, liquid, oral preparations that are usually prescribed for the relief of cough.
Use: Linctuses are used for treatmentof cough.
Active ingredients: They contains sedatives and expectorants.
Vehicle:
Syrup IP (67%w/w or 85%w/v sucrose solution) – has sweet taste, has preservative action, viscous.
Glycerol – has demulcent action, sweet in taste.
Sorbitol – Used in preparations for diabetic patients, viscous.
Invert Sugar – Sweet and viscous.
[N.B. Demulcents are inert substances that soothe inflammed mucous membrane or skin by preventing contact with air/irritants in
the surroundings.]
Adjuncts:
Chemical stabilizers – Invert sugar has reducing action. This reduces the oxidative degradation of various colors and flavors.
Hence color and flavors of fruit juices are better preserved in invert syrup.
Coloring agents: Coal tar dyes e.g. Amaranth – red color. e.g. Compound Tartrazine Solution – yellow color.
Flavoring agents: e.g. Tolu Syrup, Fruit flavors like lemon and blackcurrant, Oxymel – has acidic, honey-like sweet taste.,
Benzaldehyde Spirit – has almond-like flavor.
Preservatives: Syrup (67%w/w) has high osmotic pressure hence acts as self-preservative. Chloroform Spirit, Benzoic acid solution
Examples of Linctuses:
(i) Codeine Linctus, paediatric B.P.C. (ii) Codeine Linctus, Diabetic
(iii) Diamorphine Linctus (iv) Compound Tolu Linctus, Paediatric
 COLLODIONS
Collodions are liquid preparations for external use. They are applied with a brush. The vehicle is volatile and evaporates on
application to the skin, leaving a flexible, protective film covering the site.
· The volatile solvents are ether and alcohol.
· The film-producing ingredient is pyroxylin (nitrocellulose).
· The substance giving the flexibility is called plasticizer. Here castor oil acts as plasticizer.
Classification of collodions
(i) Unmedicated Collodion e.g. Flexible Collodion IP. This is useful for protecting small cuts and abrasions.
(ii) Medicated Collodion e.g. Salicylic acid collodion BPC contains 12%w/v salicylic acid in flexible collodion. These are provided for
prolonged contact between the skin and medicament (drug).
Method of preparation:
(i) Pyroxylin is immersed in the alcohol (90%v/v) in a bottle.
(ii) Colophony and the Castor oil are added.
(iii) Suffcient solvent ether is added.
(iv) The bottle is closed and shaken and allowed to stand for a few days, while impurities settle and then the supernatant solution is
decanted.
N.B.
Pyroxylin is a nitrated cellulose obtained by treating defatted cotton with a mixture of nitric and sulfuric acid. Its principal constituent
is cellulose tetranitrate.
It is highly inflammable, so it is kept moist with methylated spirit and stored loosely packed, in a well-closed container, protected
from light and in a cool place. Before use it is allowed to dry in air.
Collophony / Rosin: It is pale-yellow or brownish yellow glass-like solid residue left after distilling volatile oil from the oleoresin
obtained from species of pinus. It is used for its adhesive quality.
Storage
· Air tight container is used to reduce the evaporation of organic solvents.
· Smaller bottles (5ml) are used because from larger bottle the loss of solvent is higher whenever the cap is removed.
· The cap is fitted with a brush, or glass rod or a plastic applicator.
· The bottle should be amber colored and fluted.
N.B. Fluted bottles are used for external preparations.
Label:
‗For external use only‘; ‗Store in a cool place‘, ‗Highly inflammable, keep away from naked flame.‘
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PURPH 405: PHARMACY PRACTICE – I
 THROAT PAINT
PAINT: Paints are liquids for application to the skin or mucous membranes. Skin paints often have a volatile solvent that
evaporates quickly to leave a dry resinous film of medicament.
THROAT PAINT: Throat paints are more viscous due to a high content of glycerol, designed to prolong contact of the medicament
with the affected site.
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 LINIMENT
Liniment is a medicated topical preparation for application to the skin. Preparations of this type are also called balm.
Liniments are of a similar viscosity to lotions (being significantly less viscous than an ointment or cream) but unlike a lotion a
liniment is applied with friction; that is, a liniment is always rubbed in.
Liniments are typically sold to relieve pain and stiffness, such as from sore muscles or from arthritis. These liniments typically
are formulated from alcohol, acetone, or similar quickly evaporating solvents and contain counterirritant aromatic chemical
compounds such as methyl salicilate, benzoin resin, or capsaicin.
Liniments may be used on the legs and body, but should not be applied to more sensitive areas such as the head, genitals
 LOTION
 A lotion is a low- to medium-viscosity topical preparation intended for application to unbroken skin.
 Lotions are applied to external skin with bare hands, a clean cloth, cotton wool or gauze. Many lotions, especially hand
lotions and body lotions are formulated not as a medicinedelivery system, but simply to smooth, re-hydrate, and soften the skin.
These are particularly popular with the aging and aged demographic groups, and in the case of face usage, can also be
classified as a cosmetic in many cases, and may contain fragrances.
 Most lotions are oil-in-water emulsions using a substance such as cetearyl alcohol to keep the emulsion together, but water-in-oil
lotions are also formulated. The key components of a skin care lotion, cream or gel emulsion (that is mixtures of oil and water)
are the aqueousand oily phases, an emulgent to prevent separation of these two phases, and, if used, thedrug substance or
substances. A wide variety of other ingredients such as fragrances, glycerol, petroleum jelly, dyes, preservatives, proteins and
stabilizing agents are commonly added to lotions.
 Lotions can be used for the delivery to the skin of medications such as:
 Antibiotics
 Antiseptics
 Antifungals
 Corticosteroids
 Anti-acne agents
 Soothing, smoothing, moisturizing or protective agents (such as calamine)
Manufacturing process
Since thickness and consistency are key factors in lotions and creams, it is important to understand the manufacturing process that
determines viscosity.
Manufacturing lotions and creams can be completed in two cycles:
1. Emollients and lubricants are dispersed in oil with blending and thickening agents.
2. Perfume, color and preservatives are dispersed in the water cycle. Active ingredients are broken up in both cycles depending on
the raw materials involved and the desired properties of the lotion or cream.
A typical oil-in-water manufacturing process might go like this:
• Step 1: Add flake/powder ingredients to the oil being used to prepare the oil phase.
• Step 2: Disperse active ingredients.
• Step 3: Prepare the water phase containing emulsifiers and stabilizers.
• Step 4: Mix the oil and water to form an emulsion. (Note: This is aided by heating to between 110-185 F (45-85 C) depending on
the formulation and viscosity desired.)
• Step 5: Continue mixing until the end product is uniform
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PURPH 405: PHARMACY PRACTICE – I
 PESSARIES
 A Pessary is a medical device inserted into the vagina, either to provide structural support, or as a method of delivering
medication.
 Different types of pessaries
 Therapeutic pessaries: A therapeutic pessary is a medical device similar to the outer ring of a diaphragm. Therapeutic
pessaries are used to support the uterus, vagina, bladder, or rectum. A pessary is most commonly used to
treat prolapse of the uterus. It is also used to treat stress urinary incontinence, a retroverted
uterus, cystocele and rectocele. Historically, pessaries may have been used to perform abortions.
The pessary can be placed temporarily or permanently, and must be fitted by a physician, midwife, or advanced practice
nurse. Some pessaries can be worn duringintercourse.
 Pharmaceutical pessaries: A pharmaceutical pessary is used as a very effective means of delivery of pharmaceutical
substances easily absorbed through the skin of the vagina or rectum, or intended to have action in the locality, for
example against inflammation or infection, or on the uterus.
 Occlusive pessaries: An occlusive pessary is generally used in combination with spermicide as a contraceptive.
 Stem pessary: The stem pessary, a type of occlusive pessary, was an early form of the cervical cap. Shaped like a dome,
it covered the cervix, and a central rod or "stem" entered the uterus through the os, to hold it in place.
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