Assessment of Therapy and Pharmaceutical Care.ppt

assessmentoftherapyandpharmaceuticalcare,(ref:appliedtherapeutics8th)新竹馬偕紀念醫院羅凱薰藥師,pharmaceuticalcare,2005/4/20,3,“theresponsibleprovisionofdrugtherapytoachievedefiniteoutcomesthatareintendedtoimproveapatientsqualityoflife.”“提供藥事照顧是藥師的責任，以提供直接且負責的藥物治療相關服務為宗旨，且以提升病人生活品質為目標”1993americansocietyofhospitalpharmacists,藥事照顧及臨床藥學之差異,藥事照顧標準作法,收集與分析患者基本資料分辨目前藥物治療的問題歸納患者的醫療照顧上的需求設定藥物治療之目標訂定藥物治療與監測計劃與其他醫療人員討論及修正藥物治療與監測計劃執行藥物治療計劃監測藥物療效再修正藥物的治療及修正藥物治療計劃1996americansocietyofhospitalpharmacists.,2005/4/20,6,重新定義,執業人員需以負責任態度滿足病患與藥物有關的需求，並對提供服務後的結果予以負責藥師照顧病患所有用藥的需求(醫療問題及藥物問題)，不能只單就一種疾病或藥物為問題，因為病人的健康狀況是整體性strand1998,assessmentoftherapy,藥師應具備能力,knowledgeofdiseasetherapeuticplanningskillsknowledgeoflaboratoryanddiagnostictestingphysicalassessmentskillsknowledgeofdrugtherapyknowledgeofnon-drugtherapydruginformationskillspatientmonitoringskillscommunicationskills,2005/4/20,9,assessmentoftherapy,establishingthepatientrecord(資料建立)organizingthepatientrecord(整合資料)systematicapproachestopatienttherapyassessment(系統性達到評估),2005/4/20,10,establishingthepatientrecord-1,建立patientrecord能提供可得的資訊，進而確定及評估醫療上問題。directobservations(eg.physicalappearance,mentalacuity,insulin-injectiontechnique)physicalexamination(eg.bloodpressure,pulse)laboratorytests(eg.bloodglucose,cholesterollevels),2005/4/20,11,establishingthepatientrecord-2,knowledge包含全盤性藥物治療，藥物及疾病的關係，藥物治療下所預期應有結果。sourcesofpatientinformation成功評估及監測需匯集相關性資訊(獲得subjectivedata或是監測objectivephysicaldata)-data-richenvironment:hospital,long-termcarefacility-data-poorenvironment:clinicianoftenisrequiredtomakeassessmentwithlimitedinformation,2005/4/20,12,establishingthepatientrecord-3,interviewingthepatient使用聆聽、肢體語言、音調等技巧及敘述病史方式溝通-open-endedquestions:requirepatienttoexplainandelaborate-close-endedquestions:yesorno,2005/4/20,13,organizingthepatientrecord-1,提供pharmaceuticalcare應有標準化格式去紀錄病人資訊，病人紀錄(patientrecord)應涵蓋thehistory,assessment,plan.medicalhistory:isessentialtotheprovisionofpharmaceuticalcaredrughistory:-drugidentificationanduse-assessmentoftherapeuticresponse-assessmentofadverseeffects-以上方法能快速評估病人使用藥物的情況,2005/4/20,14,organizingthepatientrecord-2,socialhistory:病人的生活型態及本身態度通常能決定藥物治療成功或是失敗-work-exercise-diet-supportsystems(whoelseliveswithu?doseiteverstrainyourrelationship?)-attitude,2005/4/20,15,systematicapproachestopatienttherapyassessment1,系統性評估病人的治療problem-orientedmedicalrecord(pomr)approach-problemlist-subjectiveandobjectivedata-assessment-plan-diagnosticplan-pharmaceuticalcareplan-therapeuticobjectives-patienteducation,elementsoftheproblem-orientedmedicalrecord,soapnote,illustrationofsoap,subjective(symptoms)-ptfeels-observinghowtheptlooks,talks,acts,respondssubjectiveinformationobjective(sign)-vs,findingonpe,resultsoflabtests,findingofdiagnosticprocedures(x-ray,ct,ecg)assessment-etiology,iftherapyisindicated,currenttherapyand/ornewtherapyplan-therapeutic,drugstobeavoided,goals,monitoring(therapeuticmildgingivalhyperplasia,bilateralnystagmusandataxicgait,otherwisenonfocalneurologicexamination;remainingexaminationwnl.4.labs:admissionphenytoinconcentration:39.6mcg/ml;albumin:4.4g/dl,repeatlevel2hourslater:39.4mcg/ml.previousphenytoinconcentrationon92/8/8,dilantin:10.5mcg/ml.,2005/4/20,42,medication:藥名劑量/用法timerelatedproblemphenytoin(100)3#qhs2/12/8p1,p2,p7,p8hydrochlorothiazide(25)1#qd/am2/12/8p6prochlorperazine(5)2#q6hprn2/12/8p2,p4fluoxetine(20)1#qam2/12/8p5chemotherapyfluorouracil(5-fu)(250)2.8vialfourthcycleon2/5p3leucovorin(50)0.7vialfourthcycleon2/5p3,2005/4/20,43,a:1.s.s.withsupratherapeuticphenytoinlevelsandsymptomsconsistentwithphenytointoxicity.2.fluoxetineisainhibitorofcytochromep4502c9andthetemporalrelationshipbetweeninitiationoffluoxetinefordepressionandthenewonsetcnssymptomssuggestsapossibledrug-druginteraction.suggestion:1.considerdiscontinuefluoxetineandtemporarilydiscontinuingphenytoin.,2005/4/20,44,2.considercitalopram,mitrazapine,orvenlafaxineforthetreatmentofdepression.3.monitoringserumphenytoi