哮喘和COPD的药学监护课件.ppt

1、哮喘和慢性阻塞性肺病哮喘和慢性阻塞性肺病的药学监护的药学监护王王 卓卓卫生部临床药师（师资）培训基地中国人民解放军临床药学中心第二军医大学长海医院药学部l药学监护的理解与回顾l实施药学监护的标准模式l临床药师提供的药学监护l哮喘患者药学监护要点lCOPD患者药学监护要点药学监护的理解与回顾pharmaceutical carel药学监护来源于美国，国内又称药学服务。l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。药学服务的目的l获得改善病人生活质量的既定结果。l包括：l 治愈疾病；l 消除或

2、减轻症状；l 阻止或延缓疾病进程；l 防止疾病或症状的再次发生。IntroductionlPharmaceutical CareThe direct,responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patients quality of life(ASHP Statement on Pharmaceutical Care)What a pharmacist does to improve patient care and

3、patient safetyPharmaceutical CarelA patient-centered practicelPractitioner assumes responsibility for a patients drug related needslPractitioner is held accountable for the care provided工作开展l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。工作职责l药师对

4、治疗结果负责对治疗结果负责至少表现为以下三个方面：l 发现潜在的或实际存在的用药问题；l 解决实际发生的用药问题；l 防止潜在的用药问题发生。药学监护与药物治疗l药物治疗是临床治疗的主要方式之一l药物治疗是多学科协作的临床服务l药学监护是优化药物治疗的主要手段l药学监护是临床药师的工作核心实施药学监护的标准模式ASHP guidelines on a standardized method for pharmaceutical care.Am J Health-Syst Pharm.1996;53:17136.Functions of Pharmaceutical Care Collectin

5、g and organizing patient-specific information,Determining the presence of medication-therapy problems,Summarizing patients health care needs,Specifying pharmacotherapeutic goals,Designing a pharmacotherapeutic regimen,Designing a monitoring plan,Developing a pharmacotherapeutic regimen and correspon

6、ding monitoring plan in collaboration with the patient and other health professionals,Initiating the pharmacotherapeutic regimen,Monitoring the effects of the pharmacotherapeutic regimen,and Redesigning the pharmacotherapeutic regimen and monitoring plan.Collecting and Organizing Pertinent Patient-S

7、pecific InformationDetermining the Presence of Medication-Therapy Problems Medications with no medical indication,Medical conditions for which there is no medication prescribed,Medications prescribed inappropriately for a particular medical condition,Inappropriate medication dose,dosage form,schedul

8、e,route of administration,or method of administration,Therapeutic duplication,Prescribing of medications to which the patient is allergic,Actual and potential adverse drug events,Actual and potential clinically significant drugdrug,drugdisease,drugnutrient,and druglaboratory test interactions,Interf

9、erence with medical therapy by social or recreational drug use,Failure to receive the full benefit of prescribed medication therapy,Problems arising from the financial impact of medication therapy on the patient,Lack of understanding of the medication therapy by the patient,and Failure of the patien

10、t to adhere to the medication regimen.lSummarizing Patients Health Care Needs.lSpecifying Pharmacotherapeutic Goals.lDesigning a Pharmacotherapeutic Regimen.lDesigning a Monitoring Plan for the Pharmacotherapeutic Regimen.lDeveloping a Pharmacotherapeutic Regimen and Corresponding Monitoring Plan.lI

11、nitiating the Pharmacotherapeutic Regimen.lMonitoring the Effects of the Pharmacotherapeutic Regimen.lRedesigning the Pharmacotherapeutic Regimen andMonitoring Plan.Developing a Pharmaceutical Care PlanlStep 1.Gathering InformationlThe pharmacist should gather an accurate medication history,includin

12、g both prescription and nonprescription medications and the reasons the medications were prescribed or taken.lThe pharmacist will likely have to obtain some information from the physician,such as laboratory test results and hospitalizations.l Once this information is compiled,the preparation of a PC

13、P(Pharmaceutical Care Plan)can begin.lStep 2.Identifying ProblemslFrom the patients medication profile,only one problem is evident:diagnosis of asthma.If applicable,other problem should also be listed.lSubjective findings are those that the patient describes(e.g.,I feel tired all the time,“I feel bl

14、oated,”or I woke up coughing).lObjective findings are those that can be observed or measured by the pharmacist(e.g.,patient appears tired,blood pressure is 180/105,pitting edema in ankles).lIn the patient with asthma,the pharmacist would have the patient use a peak expiratory flow meter and record t

15、he results.lStep 3.Assessing ProblemslThe pharmacist analyzes and integrates the information gathered in steps 1 and 2 and draws conclusions in preparation for developing a patient-specific PCP.lFor example,in the asthma case,the pharmacist may first investigate the etiology of the factors that exac

16、erbated the asthma.lThe pharmacist should attempt to determine if drugs(eg.,aspirin,nonsteroidal anti-inflammatory agents,or beta-blockers)caused or exacerbated the asthma in the patient.Thus,the importance of an accurate and complete drug history becomes evident.lNext,the pharmacist assesses the se

17、verity of the asthma.This could be accomplished by determining the PEFR,examining the patients daily symptom and peak flow diary,or determining if the patient had been hospitalized and placed on steroids or a mechanical ventilator.lStep 4.Developing the PlanlThe pharmacist establishes goals linked t

18、o each of the patients problems and specifies a course of action aimed at meeting each goal.lEach goal(i.e.,desired improvement)should be stated in terms of measurable outcomes that indicate the extent to which the particular problem has been resolved.lOften,the patient has several problems,and the

19、plan must be comprehensive enough to have a positive effect on the overall health of the patient.lStep 5.Evaluating the Achievement of OutcomeslOutcomes that will be used to evaluate the success of the PCP treatment plan must be meaningful,measurable,and manageable.lOutcomes are specific,measurable

20、indicators for the goals of treatment.Thus,they should be identified in the planning process.lThe outcomes listed for asthma would include,but not be limited to,llower frequency and severity of acute exacerbations,lfewer physician office visits,lelimination of side effects,l PEFRs that never fall be

21、low 80%of previous personal-best predicted rates,lfewer emergency department visits,lmaintenance of activities that enhance the patients quality of life and may have been limited by the disease.lDocumentation should include these components.1.Patient data such as name,medical record number,location,

22、date of hospital admission(if applicable).age,sex,height,weight,known medication or other allergies,and medication history.2.Name of pharmacist(s)responsible for developing and implementing the PCP.3.Patient problem(s)listed Individually in order of potential pharmacotherapeutic impact(highest to lo

23、west priority).4.Date on which a patient problem is identified.Many diseases remain chronic throughout the patients life.Problems such as urinary tract infection or upper respiratory tract infection usually resolve in 10 to 14 days.临床药师提供的药学监护哮喘的药学监护COPD的药学监护支气管哮喘诊断流程图病史病史典型典型反复发作喘息、气急、胸闷或咳嗽多与接触刺激性因

24、素有关。症状可缓解有节律性波动规律不典型不典型体检体检异常异常哮鸣音呼气相延长无异常无异常 发现发现肺功能肺功能通气功能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？哮喘的分级持续有症状持续有症状体力活动有限体力活动有限每天有症状每天有症状影响活动和睡眠影响活动和睡眠频繁频繁每周每周1次次每个月每个月 2次，但次，但 30%60-80%预计值预计值变异率变异率 30%80%预计值预计值变异率变异率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）每周每周1次，

25、次，发作间歇无症状发作间歇无症状GINA 2010 每个月每个月 2次次80%预计值预计值变异率变异率 20%哮喘分级用药建议轻度持续重度持续中度持续舒利迭50/100 bid-50/250 bid舒利迭50/250 bid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GINA 2002 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 适级开始治疗适级开始治疗 哮喘控 制至少 3个月降级

26、治疗 哮喘长期治疗分级方案哮喘长期治疗分级方案Global Initiative for Asthma(2009)哮喘的管理模式 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Global Initiative for Asthma 建立个人诊治计划在病区开展药学监护的一般程序 步骤步骤1 1 了解病情了解病情 P Patientatient步骤步骤2 2 审核方案审核方案 R Review eview 步骤步骤3 3 确定方案确定方案 D Decisionecision步骤步骤4 4 方案注释方案注释 A Annotationnnotation步骤步骤5 5 监护要点监护要

27、点 C Care pointsare points 步骤步骤6 6 用药教育用药教育 E Education ducation 步骤步骤7 7 观察反应观察反应 M Monitor onitor 步骤步骤8 8 评估反馈评估反馈 A Assessmentssessment全面了解患者目前病情、治疗全面了解患者目前病情、治疗目标和用药史目标和用药史确认药物选择、给药方法安全、确认药物选择、给药方法安全、适当适当帮助患者优化用药方案帮助患者优化用药方案制定用药方案执行细节制定用药方案执行细节用药过程中加强安全性和有效用药过程中加强安全性和有效性观察的要点及节点性观察的要点及节点加强患者对医嘱的理解

28、和正确加强患者对医嘱的理解和正确执行，提高依从性和疗效执行，提高依从性和疗效观察药物治疗的效果和各种不观察药物治疗的效果和各种不良反应良反应对现行治疗方案进行评估，并对现行治疗方案进行评估，并进一步优化进一步优化步骤步骤1 1 了解病情了解病情步骤步骤2 2审核方案审核方案步骤步骤3 3确定方案确定方案步骤步骤4 4方案注释方案注释步骤步骤5 5监护要点监护要点步骤步骤6 6 用药教育用药教育步骤步骤7 7 观察反应观察反应步骤步骤8 8 评估反馈评估反馈主要目的步骤步骤1：了解病情了解病情l病人一般情况：年龄、性别、身高、体重、职病人一般情况：年龄、性别、身高、体重、职业等；业等；l特殊病理

29、生理：老年、儿童、哺乳、妊娠；肝、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；肾功能、特殊用药史、药物不良反应史；l疾病情况疾病情况：病变部位、范围、病因、诱因；疾：病变部位、范围、病因、诱因；疾病分型、分期、分度；病分型、分期、分度；并发症、并存疾病；并发症、并存疾病；l治疗目标：治疗目标：l理想目标和可行目标理想目标和可行目标l主要矛盾和次要矛盾：轻重缓急主要矛盾和次要矛盾：轻重缓急疾病情况疾病情况l肺炎：感染部位、范围、分型、严重程度、肺炎：感染部位、范围、分型、严重程度、病原病原l支气管哮喘：分期、分级支气管哮喘：分期、分级lCOPD：分期、肺功能分级

30、、诱因、并发：分期、肺功能分级、诱因、并发症（感染、心衰、呼衰）症（感染、心衰、呼衰）l肺癌：细胞分型、分级、分期肺癌：细胞分型、分级、分期方式与特点l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l药师与患者直接接触、与医护人员合作步骤步骤2：审核方案：审核方案l药物选择是否适当：品种、规格、剂量、药物选择是否适当：品种、规格、剂量、适应证、禁忌证；适应证、禁忌证；l给药方法是否正确：给药途径、给药时间、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；给药疗程、配伍情况、联用情况；l是否还有优化可能：有无是否还有优化可能：有无遗漏遗漏、有无、有无重

31、复重复、有无更佳的替代有无更佳的替代方式与特点l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l药师与医生紧密协作 步骤步骤3：确定方案：确定方案l确定药品、联合用药、配伍品种；确定药品、联合用药、配伍品种；l确定给药剂量、给药时间、疗程；确定给药剂量、给药时间、疗程；l确定给药途径和方法确定给药途径和方法方式与特点l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l药师充分发挥药学理论与医生合作确定。步骤步骤4：方案注释：方案注释l注释药品领取细节；注释药品领取细节；l注释药品溶解、

32、配伍细节；注释药品溶解、配伍细节；l注释药品运送保存细节；注释药品运送保存细节；l注释给药浓度、速度、步骤、顺序细节；注释给药浓度、速度、步骤、顺序细节；方式与特点l对用药方案的执行细节进行药学注释，如静脉给药时的滴速、稳定性、用药中应观察的指标等注意事项；吸入剂的正确使用方法和注意事项l药师与护理人员及患者相互交流、共同协作步骤步骤5：监护要点监护要点l医嘱是否按时执行？医嘱是否按时执行？l给药顺序、给药方法是否符合医嘱？给药顺序、给药方法是否符合医嘱？l是否注意特殊要求？是否注意特殊要求？l给药过程中有无特殊反应？给药过程中有无特殊反应？l给药后如何、何时、观察哪些疗效指标？给药后如何、何

33、时、观察哪些疗效指标？l如何预防、发现、鉴别、处理如何预防、发现、鉴别、处理ADE？方式与特点l在用药过程中监护患者正确用药情况，观察静脉药物滴速是否准确，观察患者的各种反应；若有不良反应及时进行调整和处理l药师严密观察患者的用药情况，随时与医护人员及患者沟通反馈步骤步骤6：用药教育：用药教育l患者对用药教育的需求患者对用药教育的需求l疾病对用药教育的需求疾病对用药教育的需求l药物对用药教育的需求药物对用药教育的需求l常规对用药教育的要求常规对用药教育的要求方式与特点l可以贯穿于用药前、用药过程中及用药后，运用各种方式纠正患者的用药偏差l药师与患者以各种方式交流，并取得患者信任步骤步骤7：观察

34、反应：观察反应l观察指标、时间、频率观察指标、时间、频率l分析、鉴别、评价分析、鉴别、评价l特殊情况的处理预案特殊情况的处理预案方式与特点l药师及护理人员通过对给药过程观察及与患者交流和进行相关指标的检查，观察治疗效果，如观察患者肺功能、动脉血气、血常规等感染相关指标以及临床表现等情况，及时分析和发现潜在药物相关问题。l药师与护理人员协作观察，并与医生及时交流步骤步骤8：评估反馈：评估反馈l原有治疗方案是否达到预期效果？原有治疗方案是否达到预期效果？l病情有何发展变化？病情有何发展变化？l原有治疗目标是否需要调整？原有治疗目标是否需要调整？l患者对现有治疗方案的依从性和耐受性如何？患者对现有治疗方案的依从性和耐受性如何？l是否有必要对现有方案进行调整？是否有必要对现有方案进行调整？l如何调整？如何调整？方式与特点l通过一个阶段药物治疗效果的观察，结合目前病情变化，对现行药物治疗方案进行调整；若疗效不佳时，既要考虑到治疗方案本身的问题，也要考虑对病情估计不全面导致治疗目标的不准确，因此必要时应重新确定治疗目标。l药师可以通过记录药历或病例分析的形式对治疗方案综合分析，并书面或通过病例讨论或与医生口头交流时提出下一步建议。