哮喘和COPD的药学监护ppt课件

哮喘和慢性阻塞性肺病的药学监护,1,药学监护的理解与回顾实施药学监护的标准模式临床药师提供的药学监护哮喘患者药学监护要点COPD患者药学监护要点,2,药学监护的理解与回顾,3,pharmaceuticalcare,药学监护来源于美国，国内又称药学服务。其核心思想是通过药师与临床医护人员共同协作，为病人提供直接负责的药物治疗，并积极监测治疗的全过程，以改善病人的治疗效果，最终提高病人的生活质量为目标。,4,药学服务的目的,获得改善病人生活质量的既定结果。包括：治愈疾病；消除或减轻症状；阻止或延缓疾病进程；防止疾病或症状的再次发生。,5,Introduction,PharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatientsqualityoflife(ASHPStatementonPharmaceuticalCare)Whatapharmacistdoestoimprovepatientcareandpatientsafety,6,PharmaceuticalCare,Apatient-centeredpracticePractitionerassumesresponsibilityforapatientsdrugrelatedneedsPractitionerisheldaccountableforthecareprovided,7,工作开展,药学监护是药师在临床疾病治疗中参与并主导的一种工作过程，是多学科协作综合地考虑整体诊疗计划的前提下，从药学角度对治疗计划进行合理的设计、执行、监测和及时调整，实施过程需要患者和医护人员紧密协作。,8,工作职责,药师对治疗结果负责至少表现为以下三个方面：发现潜在的或实际存在的用药问题；解决实际发生的用药问题；防止潜在的用药问题发生。,9,药学监护与药物治疗,药物治疗是临床治疗的主要方式之一药物治疗是多学科协作的临床服务药学监护是优化药物治疗的主要手段药学监护是临床药师的工作核心,10,实施药学监护的标准模式,ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:17136.,11,FunctionsofPharmaceuticalCare,Collectingandorganizingpatient-specificinformation,Determiningthepresenceofmedication-therapyproblems,Summarizingpatientshealthcareneeds,Specifyingpharmacotherapeuticgoals,Designingapharmacotherapeuticregimen,Designingamonitoringplan,Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,Initiatingthepharmacotherapeuticregimen,Monitoringtheeffectsofthepharmacotherapeuticregimen,andRedesigningthepharmacotherapeuticregimenandmonitoringplan.,12,CollectingandOrganizingPertinentPatient-SpecificInformation,13,14,15,DeterminingthePresenceofMedication-TherapyProblems,Medicationswithnomedicalindication,Medicalconditionsforwhichthereisnomedicationprescribed,Medicationsprescribedinappropriatelyforaparticularmedicalcondition,Inappropriatemedicationdose,dosageform,schedule,routeofadministration,ormethodofadministration,Therapeuticduplication,Prescribingofmedicationstowhichthepatientisallergic,Actualandpotentialadversedrugevents,Actualandpotentialclinicallysignificantdrugdrug,drugdisease,drugnutrient,anddruglaboratorytestinteractions,Interferencewithmedicaltherapybysocialorrecreationaldruguse,Failuretoreceivethefullbenefitofprescribedmedicationtherapy,Problemsarisingfromthefinancialimpactofmedicationtherapyonthepatient,Lackofunderstandingofthemedicationtherapybythepatient,andFailureofthepatienttoadheretothemedicationregimen.,16,SummarizingPatientsHealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.,17,DevelopingaPharmaceuticalCarePlan,Step1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.,18,Step2.IdentifyingProblemsFromthepatientsmedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,Ifeeltiredallthetime,“Ifeelbloated,”orIwokeupcoughing).Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.,19,Step3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatientsdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.,20,Step4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatientsproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.,21,Step5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatientsqualityoflifeandmayhavebeenlimitedbythedisease.,22,Documentationshouldincludethesecomponents.1.Patientdatasuchasname,medicalrecordnumber,location,dateofhospitaladmission(ifapplicable).age,sex,height,weight,knownmedicationorotherallergies,andmedicationhistory.2.Nameofpharmacist(s)responsiblefordevelopingandimplementingthePCP.3.Patientproblem(s)listedIndividuallyinorderofpotentialpharmacotherapeuticimpact(highesttolowestpriority).4.Dateonwhichapatientproblemisidentified.Manydiseasesremainchronicthroughoutthepatientslife.Problemssuchasurinarytractinfectionorupperrespiratorytractinfectionusuallyresolvein10to14days.,23,24,25,临床药师提供的药学监护,哮喘的药学监护COPD的药学监护,26,支气管哮喘诊断流程图,病史,典型反复发作喘息、气急、胸闷或咳嗽多与接触刺激性因素有关。症状可缓解有节律性波动规律,不典型,体检,异常哮鸣音呼气相延长,无异常发现,肺功能,通气功能,PEF监测,阻塞性障碍,正常,舒张试验,激发试验,排除其他肺部疾病,阳性,变异率,正常,阴性,阳性,阴性,COPD？,27,哮喘的分级,持续有症状体力活动有限,每天有症状影响活动和睡眠,每周1次，但每个月2次，但30%,60-80%预计值变异率30%,80%预计值变异率20-30%,治疗前哮喘病情严重程度分级,症状,夜间症状,FEV1或峰流速,重度持续（第4级）,中度持续（第3级）,轻度持续（第2级）,间歇状态（第1级）,每周1次，发作间歇无症状,GINA2010,每个月2次,80%预计值变异率20%,28,哮喘分级用药建议,此建议仅供参考，具体详见GINA2002,29,一级,二级,三级,四级,降级治疗,间断发作,轻度持续,中度持续,严重持续,适级开始治疗,哮喘控制至少3个月降级治疗,哮喘长期治疗分级方案,GlobalInitiativeforAsthma(2009),30,哮喘的管理模式,31,哮喘管理计划,教育,评价和监护哮喘,避免诱因,急性发作的治疗计划,规律随访,GlobalInitiativeforAsthma,建立个人诊治计划,32,在病区开展药学监护的一般程序,33,主要目的,34,步骤1：了解病情,病人一般情况：年龄、性别、身高、体重、职业等；特殊病理生理：老年、儿童、哺乳、妊娠；肝、肾功能、特殊用药史、药物不良反应史；疾病情况：病变部位、范围、病因、诱因；疾病分型、分期、分度；并发症、并存疾病；治疗目标：理想目标和可行目标主要矛盾和次要矛盾：轻重缓急,35,疾病情况,肺炎：感染部位、范围、分型、严重程度、病原支气管哮喘：分期、分级COPD：分期、肺功能分级、诱因、并发症（感染、心衰、呼衰）肺癌：细胞分型、分级、分期,36,方式与特点,通过问诊、体检、观察及阅读病历及各类检查资料，了解与药疗有关的基本情况药师与患者直接接触、与医护人员合作,37,步骤2：审核方案,药物选择是否适当：品种、规格、剂量、适应证、禁忌证；给药方法是否正确：给药途径、给药时间、给药疗程、配伍情况、联用情况；是否还有优化可能：有无遗漏、有无重复、有无更佳的替代,38,方式与特点,每当新开处方或治疗方案更改时审核处方，特别要考虑患者的病理、生理状况及合并用药之间的相互作用，考虑药物的不良反应与治疗利益的相互关系药师与医生紧密协作,39,步骤3：确定方案,确定药品、联合用药、配伍品种；确定给药剂量、给药时间、疗程；确定给药途径和方法,40,方式与特点,了解患者的具体情况，并考虑所用药物的药代/药效学特点，优化并确定给药方案药师充分发挥药学理论与医生合作确定。,41,步骤4：方案注释,注释药品领取细节；注释药品溶解、配伍细节；注释药品运送保存细节；注释给药浓度、速度、步骤、顺序细节；,42,