美国药师药学实践课件

1、第一页，共二十七页。第二页，共二十七页。第三页，共二十七页。第四页，共二十七页。第五页，共二十七页。第六页，共二十七页。“早上好！李先生。我姓杨，是早上好！李先生。我姓杨，是主管你的住院药师。我需要主管你的住院药师。我需要(xyo)向您了解一些信息，以便更清楚向您了解一些信息，以便更清楚地了解您的情况。您不介意我问地了解您的情况。您不介意我问一些问题吧？一些问题吧？”第七页，共二十七页。所有病史及用药史信息被归所有病史及用药史信息被归纳入一个结构化的表格中！纳入一个结构化的表格中！第八页，共二十七页。Pharmacotherapy Workup notes - ASSESSMENTpatien

2、t reason for encounter:CONTACT INFORMATIONNameAddressCityStatePostal CodeTelephone (h)(w)(cell)e-mailPharmacy NameClinic Name(tel)(tel)DEMOGRAPHICSAgeDate of BirthGender: M/FWeightHeightLean Body WeightPregnancy status: Y/NBreast Feeding: Y/NDue DateOccupationLiving Arrangements/FamilyHealth Insuran

3、ce (coverage issues):第九页，共二十七页。SOCIAL DRUG USESubstanceHistory of UseSubstanceHistory of UseTobacco_ No tobacco use_ 0-1 packs per day_ 1 packs per day_ previous history of smoking_ attempts to quit Alcohol_ No alcohol use_ 1-2 drinks per week_ 3-6 drinks per week_ 6 drinks per week_ history of alco

4、hol dependenceCaffeine_ No caffeine use_ 6 cups per day_ history of caffeine dependenceOtherrecreationalDrug useALLERGIES & ALERTSMedication Allergies (drug, timing, reaction - rash, SOB, angioedema, anaphylaxis)Adverse reactions to drugs in the past (Intolerances)Other Alerts/Health Aids/Specia

5、l Needs (sight, hearing, mobility, literacy, disability)第十页，共二十七页。CURRENT MEDIAL CONDITIONS AND MEDICATIONSIndicationDrug ProductDosage Regimendose, route, frequency, durationStart DateResponseeffectiveness/safetyPAST DRUG THERAPIESIndicationDrug TherapyResponseDate第十一页，共二十七页。PAST MEDICAL HISTORY (r

6、elevant illnesses, hospitalization, surgical procedures, injuries, pregnancies, deliveries)PHARMACISTS OBSERVATIONS(MEDICATION EXPERIENCE)What is the patients general attitude toward taking medication?Needs attention in care planY NWhat does the patient want/expect from his/her drug therapy?Needs at

7、tention in care planY NWhat concerns does the patient have with his/her medications?Needs attention in care planY NTo what extent does the patient understand his/her medications?Needs attention in care planY NAre there cultural, religious, or ethical issues that influence the patients willingness to

8、 take medications?Needs attention in care planY NVital SignsBP_/_ HR _bpm Resp Rate _ Temp _第十二页，共二十七页。review of systemsGeneralSystemsPoor appetite GU/ReproductiveDysmenorrhea/menstrualbleedingWeight changePainIncontinenceHeadacheImpotenceDizziness (vertigo)Decreased sexual driveEENTChange in vision

9、Vaginal discharge or itchingLoss of hearingHot flashesRinging in the ears (tinnitus)Kidney/UrinaryUrinary frequencyBloody nose (epistaxis)Bloody urine (hematuria)Allergic rhinitisRenal dysfunctionGlaucomaHematopoieticSymptomsExcessive bruisingBloody sputum (hemoptysis)BleedingCardiovascularChest pai

10、nAnemiaHyperlipidemiaMusculoskeletalBack painHypertensionArthritis pain(osteo/rheumatoid)Myocardial InfarctionOrthostatic hypotensionTendonitisPulmonaryAsthmaPainful musclesShortness of breathNeuropsychiatricNumb, tingling sensationin extremities(parasthesia)WheezingGastrointestinalHeartburnAbdomina

11、l painTremorNauseaLoss of balanceVomitingDepressionDiarrheaSuicidalConstipationAnxiety, nervousnessSkinEczema/PsoriasisInability to concentrateItching (pruritis)SeizureRashStroke/TIAEndocrineSystemsDiabetesMemory lossHypothyroidismInfectiousDiseaseHIV/AIDSMenopausal SymptomsMalariaHepaticCirrhosisSy

12、philisHepatitisGonorrheaNutrition/Fluid/ElectrolytesDehydrationHerpesEdemaChlamydiaPotassium deficiencyTuberculosis第十三页，共二十七页。Drug Therapy Problem Identification/Characterization drug therapy problemsmedical condition and drug therapy involvedindicationUnnecessary Drug Therapy_No medical indication_

13、Duplicate therapy_Nondrug therapy indicated_Treating avoidable ADR_Addictive/recreationalNeeds Additional Drug Therapy_Untreated condition_Preventative/prophylactic_Synergistic/potentiatingmedical condition and drug therapy involvedeffectivenessNeeds Different Drug Product_More effective drug availa

14、ble_Condition refractory to drug_Dosage form inappropriate_Not effective for conditionDosage too low_Wrong dose_Frequency inappropriate_Drug interaction_Duration inappropriatemedical condition and drug therapy involvedsafetyAdverse Drug Reaction_Undesirable effect_Unsafe drug for patient_Drug intera

15、ction_Dosage administered or changed too rapidly_Allergic reaction_Contraindications presentDosage Too High_Wrong dose_Frequency inappropriate_Duration inappropriate_Drug interaction_Incorrect administrationmedical condition and drug therapy involvedcomplianceNoncompliance_Directions not understood_

16、Patient prefers not to take_Patient forgets to take_Drug product too expensive_Cannot swallow/administer_Drug product not available第十四页，共二十七页。Pharmacotherapy Workup notes CARE PLANINDICATION (medical condition) HISTORY OF THE PRESENT ILLNESS OR MEDICAL CONDITION (including previous approaches to tre

17、atment and responses)GOALS OF THERAPY (improvement or normalization of signs/symptoms/laboratory tests or reduction of risk)1.2.DRUG THERAPY PROBLEMS to be resolved_None at this timeTherapeutic Alternatives (to resolve the drug therapy problem and rationale)1.2.第十五页，共二十七页。PHARMACOTHERAPY PLAN (inclu

18、des current drug therapies and changes based on best therapeutic alternative choice from above)medications(drug products)dosage instructions(dose, route, frequency, duration)notes changesOther interventions to optimize drug therapy:Schedule for follow-up evaluation:第十六页，共二十七页。Pharmacotherapy Workup

19、notes FOLLOW-UP EVALUATIONMedical Condition (Indication): _Outcome ParameterPretreatmentBaseline (Date)First Follow-up(Date)Second Follow-up(Date)EffectivenessSign/symptomSign/symptomLab valueLab valueSafetySign/symptomSign/symptomLab valueLab valueOther第十七页，共二十七页。statusInitial: goals being established, initiate new therapyResolve: goals achieved, therapy completedStable: goals achieved, continue same therapyImproved: adequate progress being made, continue same therapyPartial Improvement: progress being made, adjustments in therapy requiredUnimprove