哮喘和COPD的药学监护

哮喘和慢性阻塞性肺病

的药学监护1编辑ppt药学监护的理解与回忆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编辑ppt药学监护的理解与回忆3编辑pptpharmaceuticalcare药学监护来源于美国，国内又称药学效劳。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编辑ppt药学效劳的目的获得改善病人生活质量的既定结果。包括：①治愈疾病；②消除或减轻病症；③阻止或延缓疾病进程；④防止疾病或病症的再次发生。5编辑pptIntroductionPharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatient’squalityoflife(ASHPStatementonPharmaceuticalCare)Whatapharmacistdoestoimprovepatientcareandpatientsafety6编辑pptPharmaceuticalCareApatient-centeredpracticePractitionerassumesresponsibilityforapatient’sdrugrelatedneedsPractitionerisheldaccountableforthecareprovided7编辑ppt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方案的前提下，从药学角度对治疗方案进行合理的设计、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编辑ppt工作职责药师对治疗结果负责至少表现为以下三个方面：①发现潜在的或实际存在的用药问题；②解决实际发生的用药问题；③防止潜在的用药问题发生。9编辑ppt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效劳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编辑ppt实施药学监护的标准模式ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:1713–6.11编辑pptFunctionsofPharmaceuticalCare•

Collectingandorganizingpatient-specificinformation,•Determiningthepresenceofmedication-therapyproblems,•Summarizingpatients’healthcareneeds,•Specifyingpharmacotherapeuticgoals,•Designingapharmacotherapeuticregimen,•Designingamonitoringplan,•Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,•Initiatingthepharmacotherapeuticregimen,•Monitoringtheeffectsofthepharmacotherapeuticregimen,and•Redesigningthepharmacotherapeuticregimenandmonitoringplan.12编辑pptCollectingandOrganizingPertinentPatient-SpecificInformation13编辑ppt14编辑ppt15编辑pptDeterminingthePresenceofMedication-TherapyProblems•Medicationswithnomedicalindication,•Medicalconditionsforwhichthereisnomedicationprescribed,•Medicationsprescribedinappropriatelyforaparticularmedicalcondition,•Inappropriatemedicationdose,dosageform,schedule,routeofadministration,ormethodofadministration,•Therapeuticduplication,•Prescribingofmedicationstowhichthepatientisallergic,•Actualandpotentialadversedrugevents,•Actualandpotentialclinicallysignificantdrug–drug,drug–disease,drug–nutrient,anddrug–laboratorytestinteractions,•Interferencewithmedicaltherapybysocialorrecreationaldruguse,•Failuretoreceivethefullbenefitofprescribedmedicationtherapy,•Problemsarisingfromthefinancialimpactofmedicationtherapyonthepatient,•Lackofunderstandingofthemedicationtherapybythepatient,and•Failureofthepatienttoadheretothemedicationregimen.16编辑pptSummarizingPatients’HealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.17编辑pptDevelopingaPharmaceuticalCarePlanStep1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.18编辑pptStep2.IdentifyingProblemsFromthepatient'smedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,'Ifeeltiredallthetime,“Ifeelbloated,〞or"Iwokeupcoughing").Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.19编辑pptStep3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatient'sdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.20编辑pptStep4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatient'sproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.21编辑pptStep5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatient'squalityoflifeandmayhavebeenlimitedbythedisease.22编辑pptDocumentationshouldincludethesecomponents.1.Patientdatasuchasname,medicalrecordnumber,location,dateofhospitaladmission(ifapplicable).age,sex,height,weight,knownmedicationorotherallergies,andmedicationhistory.2.Nameofpharmacist(s)responsiblefordevelopingandimplementingthePCP.3.Patientproblem(s)listedIndividuallyinorderofpotentialpharmacotherapeuticimpact(highesttolowestpriority).4.Dateonwhichapatientproblemisidentified.Manydiseasesremainchronicthroughoutthepatient'slife.Problemssuchasurinarytractinfectionorupperrespiratorytractinfectionusuallyresolvein10to14days.23编辑ppt24编辑ppt25编辑ppt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编辑ppt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。病症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编辑ppt哮喘的分级持续有病症体力活动有限每天有病症影响活动和睡眠每周1次，但<每天1次频繁≥每周1次>每个月2次，但<每周1次

60%预计值变异率>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病症夜间病症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，发作间歇无病症GINA2021≤每个月2次

80%预计值变异率<20%28编辑ppt哮喘分级用药建议轻度持续重度持续中度持续舒利迭50/100bid-50/250bid舒利迭50/250bid间歇发作辅舒酮125必可酮®250或

1喷qd辅舒酮125必可酮®250或

1喷,bidICS+LABA万托林按需使用辅舒酮®125必可酮®250＋或

1-2喷,qd若控制不好，此建议仅供参考，具体详见GINA200229编辑ppt

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(2021)30编辑ppt哮喘的管理模式31编辑ppt哮喘管理方案教育评价和监护哮喘防止诱因急性发作的治疗方案规律随访GlobalInitiativeforAsthma建立个人诊治方案32编辑ppt在病区开展药学监护的一般程序

步骤1了解病情Patient步骤2审核方案Review步骤3确定方案Decision步骤4方案注释Annotation步骤5监护要点Carepoints

步骤6用药教育Education

步骤7观察反应Monitor

步骤8评估反馈Assessment33编辑ppt全面了解患者目前病情、治疗目标和用药史确认药物选择、给药方法安全、适当帮助患者优化用药方案制定用药方案执行细节用药过程中加强安全性和有效性观察的要点及节点加强患者对医嘱的理解和正确执行，提高依从性和疗效观察药物治疗的效果和各种不良反应对现行治疗方案进行评估，并进一步优化步骤1

了解病情步骤2审核方案步骤3确定方案步骤4方案注释步骤5监护要点步骤6

用药教育步骤7

观察反应步骤8

评估反馈主要目的34编辑ppt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、药物不良反响史；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编辑ppt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编辑ppt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，了解与药疗有关的根本情况药师与患者直接接触、与医护人员合作37编辑ppt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编辑ppt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，考虑药物的不良反响与治疗利益的相互关系药师与医生紧密协作39编辑ppt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编辑ppt方式