英國臨床藥學模式和方法課件

1、英國藥學監(jiān)護實踐模式與方法 ( Pharmaceutical Care Practice in UK) 楊赴云 fyy0326sina 英國藥學監(jiān)護實踐模式與方法 ( Pharmaceutic關于“Pharmaceutical Care” 的翻譯“Pharmaceutical service” 藥學服務 “Clinical Pharmacy ”臨床藥學 “Clinical Pharmacy service”臨床藥學服務 “Pharmaceutical care” 藥學監(jiān)護關于“Pharmaceutical Care” 的翻譯“Care” 和 “Service”Care LONGMAN DICT

2、IONARY OF TEMPERARY ENGLISH Worry; anxiety; sorrow; grief; Charge; keeping; protection; responsibility;Serious attention;Carefulness in avoiding harm, damageService LONGMAN DICTIONARY OF TEMPERARY ENGLISH Work or duty done for someoneAn act or job done in favor of someone“Care” 和 “Service”Care LOCAR

3、E 大英漢詞典煩惱，憂慮，操心注意，當心，小心，謹慎關切，關心，關懷，愛護看護，照管，照顧，管理，監(jiān)護負責照管的事，負責，責任SERVICE 大英漢詞典幫傭，業(yè)務，事務：尤指公共事務業(yè)務機構，行政部門勞役，服務性工作禮拜，宗教儀式CARE 大英漢詞典ICU “Intensive Care Unit” “重癥監(jiān)護病房”CCU “Cardiac Care Unit” “心臟病監(jiān)護病房” ICU “Intensive Care Unit” 藥學服務Pharmaceutical Service范圍廣泛，所有與藥學有關的服務。如，衛(wèi)生行政藥事管理部門，企業(yè)的制藥技術服務，醫(yī)院的藥學服務等。醫(yī)院藥學部門所

4、提供的系統(tǒng)的服務，包括藥品的配制和分發(fā)，提供與藥物和疾病有關的信息，所有病人用藥劑量的監(jiān)測，審查醫(yī)生處方并錄入數(shù)據(jù)庫等。（The Department of Pharmacy provides systems-based services including drug and disease state information, drug preparation and distribution, and dosage monitoring services for all patients. ）藥學服務Pharmaceutical Service范圍廣英國臨床藥學模式和方法課件英國臨床藥學模

5、式和方法課件英國臨床藥學模式和方法課件臨床藥學Clinical Pharmacy臨床藥學是由藥學專業(yè)人員實施的，幫助臨床最大效益的使用藥物，并且將藥物的毒性降到最小的學科。（Clinical pharmacy is a discipline concerned with the application of pharmaceutical expertise to help maximise drug efficacy and minimise drug toxicity in individual patients.）臨床藥學Clinical Pharmacy臨床藥學是由藥學臨床藥學服務Cli

6、nical pharmacy service選擇用藥 藥代動力學評價給藥劑量和方法 對病人用藥的咨詢和教育 其他優(yōu)化藥物治療的方法。 臨床藥學服務Clinical pharmacy servi藥學監(jiān)護Pharmaceutical care1990年Robert Cipolle，Linda Strand將藥學監(jiān)護定義為“以病人為中心的實踐，實踐者負責病人與用藥有關的需求并為之負責” （Pharmaceutical care is a patient-centred practice in which the practitioner assumes responsibility for a pa

7、tients drug-related needs and is held accountable for this commitment.）藥學監(jiān)護Pharmaceutical care1990年R藥學監(jiān)護實踐是一次實踐針對一個病人。由三部分組成：評估病人的需求，制定監(jiān)護計劃，跟蹤評價。 （It is built up one patient at a time.It has three components: assessment of the patients needs; development of a care plan; and follow up evaluation.）藥學監(jiān)

8、護實踐是一次實踐針對一個病人。由三部分組成：評估病人的Pharmaceutical servicesClinical pharmacy servicesPharmaceutical carePharmaceutical servicesPharmacA Typical Day of a Clinical Pharmacist in UK 英國臨床藥師的一天 A Typical Day of a Clinical Morning 8:30 12:00 (Coffee break 10:00 10:30)See the blackboard Those admission Those discha

9、rge Morning 8:30 12:00 For those who discharge today Prescribing their discharge drugsContact with their local pharmacistApproach to the patient For those who discharge todayFor those who were admittedMedical historyDrug historyThe knowledge of the patientPotential drug related problemsCare planFor

10、those who were admittedWard roundDoctors, nurse and pharmacistDiscussing about the drug related needs Ward roundReview the other patients who has potential problemsSigns and symptoms of the patientsLaboratory testsDocumented Afternoon 13:00 16:30Review the other patients who Ward meetingsNurse meeti

11、ngsPharmacists meetingsDispensingLibrary Ward meetingsFor the individual patient the Minnesota Model the British Model the Canadian Model the Australia ModelFor the individual patient The Minnesota ModelHolistic ApproachThe Minnesota ModelHolistic A藥學監(jiān)護計劃（Pharmaceutical Care Plan)病人情況合并癥疾病史及用藥史協(xié)同治療藥

12、物曾有過的不良反應疾病及用藥 病人條件 選擇合適的藥藥學服務病人的旅程藥學監(jiān)護計劃病人情況協(xié)同治療藥物 病人條件藥學服務病人的旅 59歲女病人DA,因前胸劇烈疼痛,疼痛放射性的傳播到左臂,急救中心到家中急救并送到SGH 醫(yī)院急診. 病人主訴: 胸部劇烈疼痛,呈放射性傳到左 臂,惡心. 急救醫(yī)生給diamorphin后 疼痛緩解.aspirin 300mgCase 59歲女病人DA,因前胸劇烈疼痛,疼痛放射性的傳播到左臂入院檢查: BP 137/81 mmHg pulse 62 bpm respiratory rates 16 temperature 36 SaO2 97% on air Her

13、 JVP, HS were normal her chest was clear.入院檢查: 病史. Mrs DA 過去沒有疾病記載 用藥史 Mrs DA 住院前沒有用過藥物 ECG 顯示 ST 段升高, 診斷 急性下壁心肌梗塞診斷病史. Mrs DA 過去沒有疾病記載 用藥史 M病人社會關系與丈夫一起住吸煙 每天25 支 喝酒 每周20 units. 病人社會關系與丈夫一起住Unit8g or 10 ml of pure alcoholHalf a pint of ordinary strength lager/beer/cider(3.5-4% A.B.V.) = 1 unitA 25ml

14、 pub measure of a spirit (40%A.B.V) =1 unitA small glass of wine(8-9%) =1 unit 1pint = 568ml 1unit=284ml beerUnitDay 1(09/01/04)streptokinase 1.5 mu iv 鏈激酶 metoclopramide 10mg iv 甲氧氯普胺 metoprolol 25mg 美托洛爾 Enoxaparin 40mg, 依諾肝素 aspirin 75mg, 阿司匹林 simvastatin 40mg 辛伐他丁 ramipril 2.5mg 雷米普利 Paracetamol

15、 1g 撲熱息痛Day 1(09/01/04)稍后復查, ECG 顯示病人恢復良好 ,病人生命體征很好BP 113/81 mmHgpulse 73bpm RR 17 稍后復查, ECG 顯示病人恢復良好 ,病人生命體征很好Day 2(10/01/04)Mrs DA 今天沒有胸痛心律為正常竇律感覺非常疲勞, 起床時頭暈血壓BP 73-97/34-69mmHg Metoprolol 25mg bd change to atenolol 25mg bd BP123/69mmHg Day 2(10/01/04) Day 4(12/01/04)無胸痛癥狀, 生命體征穩(wěn)定活動良好,可以在病房內(nèi)走動 停用e

16、noxaparin Day 4(12/01/04) Day 5(13/01/04) BP 83-113/47-65 Nicotine 帖劑 空腹血糖 10.7 mmol/l. 建議營養(yǎng)學家重新調(diào)整飲食 Ramipril 劑量由2.5mg增加到 5mg BD 今天可以出院 Day 5(13/0Date09/0110/0112/0113/01Na (135-145) mmol/l 138135140141K (3.5-5.0) mmol/l 4.24.04.1Urea (3.3-6.0) mmol/l 4.36.34.64.5Gluc (3.9-5.0) mmol/l 11.210.7Creat

17、(70-110) mol/l 56716258TnT (180mmHg), 感染性心內(nèi)膜炎 yes 急性心梗溶栓治療路徑AMI 癥狀 ?請主治醫(yī)生復查nStreptokinase 1.5MU 50ml 0.9% NaCl or 5% glucose over 1 hour Alteplase within 6-12 hours, 10mg iv, then 50mg intravenous infusion over 60 minutesSince the presence of antistreptokinase antibodies from day 5 to 12 months post

18、 administration may render further treatment during this time ineffective, it is important to document the patient had been given streptokinase and to issue the patient with a “streptokinase card” which includes the date of administration. Streptokinase 1.5MU 50ml 0.9%英國臨床藥學模式和方法課件LifestyleImproving

19、 diet Advise patients not to take supplements containing beta-carotene.Do not advise patients to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk.Advise patients to consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fis

20、h.Consider providing at least 1 g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years for patients who have had an MI within 3 months and are not achieving 7 g of omega 3 fatty acids per week.Do not routinely initiate omega-3-acid ethyl esters sup

21、plements for patients who have had an MI more than 3 months earlier.Encourage patients to eat a Mediterranean-style diet.LifestyleImproving diet Delivering dietary Give consistent healthy eating advice that is tailored to the patients needs and that can be extended advice to the whole family.Offer p

22、atients an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet.Delivering dietary Controlling alcohol Advise patients to keep weekly alcohol consumption within safe limits (no more than 21 units of consumption alcohol per week for men or

23、 14 units per week for women) and to avoid binge drinking.Smoking cessation Advise smokers to quit and offer assistance from a smoking cessation service.Offer smokers who have expressed a desire to quit support, advice and referral to an intensive support service.If a patient is unable or unwilling

24、to accept a referral, offer pharmacotherapy.Controlling weight Offer overweight and obese patients advice and support to achieve and maintain a healthy weight.Controlling alcohol Improving physical activity levels Encourage patients to undertake sufficient regular physical activity to increase exerc

25、ise capacity.They should aim to be physically active for 2030 minutes a day to the point of slight breathlessness. For patients not achieving this, advise them to increase their activity in a step-by-step way, aiming to increase their exercise capacity. They should start at a level that is comfortab

26、le, and increase the duration and intensity of activity as they gain fitness.Discuss current and past activity levels and preferences with patients.The benefit of exercise may be enhanced by tailored advice from a suitably qualified professional.Improving physical activity leCardiac rehabilitation a

27、fter an acute MICardiac rehabilitation programmes have been consistently shown to reduce mortality rates in CHD patients. Cardiac rehabilitation is the coordinated sum of interventions required to ensure the best possible physical, psychological and social conditions to enable the CHD patient to pre

28、serve or resume optimal functioning in society. It also aims to slow or reverse progression of the disease. Cardiac rehabilitation cannot be regarded as an isolated form or stage of therapy, but must be integrated within secondary prevention services, of which it forms only one facet (WHO definition

29、, 1993).Cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component Cardiac rehabilitation after aOffer all patients who have had an acute MI treatment with a combination of the following drugs: ACE inhibitor aspirin bet

30、a-blocker statin.Drug therapy Offer all patients who have haACE inhibitors Offer ACE inhibitors early after presentation and titrate upwards to the maximum tolerated or target dose.Do not routinely prescribe ARBs unless the patient is intolerant or allergic to an ACE inhibitor.Continue ACE inhibitor

31、s indefinitely in patients with preserved LV function or LVSD, whether or not they have heart failure symptoms.Early after an acute MI, do not routinely use the combination of ACE inhibitor/ARB for patients with heart failure and/or LVSD.ACE inhibitors Assessment/monitoringAssess LV function in all

32、patients who have had an MI.Measure renal function, serum electrolytes and BP before starting an ACE inhibitor or ARB and again within 1 or 2 weeks.Monitor patients as the dose is titrated and more frequently for patients at increased risk of deterioration in renal function.Monitor patients with chr

33、onic heart failure Assessment/monitoringAntiplatelet therapyOffer aspirin and continue indefinitely.Do not offer clopidogrel alone as first-line therapy but consider it for patients with aspirin hypersensitivity. If the patient has not been treated with a combination of aspirin and clopidogrel durin

34、g the acute phase of an MI, do not routinely initiate this combination.- Clopidogrel in combination with low-dose aspirin is recommended in the management of non-ST-segment-elevation acute coronary syndrome in people who are at moderate to high risk of MI or death. It is recommended that this combin

35、ation is continued for 12 months after the most recent acute episode. Thereafter standard care, including low-dose aspirin alone, is recommended.Antiplatelet therapyFor patients after a STEMI treated with the combination of aspirin and clopidogrel during the first 24 hours, this combination should b

36、e continued for at least 4 weeks. Thereafter standard treatment including low-dose aspirin should be given unless there are other indications to continue dual antiplatelet therapy.For patients with a history of dyspepsia, consider a PPI and low-dose aspirin. For patients with a history of aspirin-in

37、duced ulcer bleeding whose ulcers have healed and who are H. pylori negative,consider a full-dose PPI and low-dose aspirin. 英國臨床藥學模式和方法課件Beta-blockersOffer a beta-blocker as soon as the patient is clinically stable and titrate upwards to the maximum tolerated dose.Continue treatment indefinitely.For

38、 patients with LVSD being offered treatment, a beta-blocker licensed for use in heart failure may be preferred. Carvedilol bisoprololBeta-blockersPotassium channel activatorsNicorandil is not recommended to reduce cardiovascular risk.Potassium channel activatorsVitamin K antagonistsHigh-intensity wa

39、rfarin (INR 3) should not be considered as an alternative to aspirin in first-line treatment.For patients unable to take aspirin or clopidogrel, consider moderate-intensity warfarin (INR 23) for up to 4 years and possibly longer.The combination of warfarin and clopidogrel is not routinely recommende

40、d.Vitamin K antagonistsCalcium channel blockersDo not routinely use calcium channel blockers for secondary prevention. If beta-blockers are contraindicated or need to be discontinued, consider diltiazem or verapamil for secondary prevention in patients without pulmonary congestion or LVSD.For patien

41、ts who are stable, calcium channel blockers may be used to treat hypertension and/or angina. For patients with heart failure, use amlodipine and avoid verapamil, diltiazem and short-acting dihydropyridine agents in line with NICE clinical guidelineCalcium channel blockersAldosterone antagonistsFor p

42、atients with symptoms and/or signs of heart failure and LVSD, initiate treatment with an aldosterone antagonist licensed for post-MI treatment within 314 days of the MI, preferably after ACE inhibitor therapy. For patients with clinical heart failure and LVSD already being treated with an aldosteron

43、e antagonist for a concomitant condition, continue with the aldosterone antagonist or an alternative, licensed for early post-MI treatment.Aldosterone antagonistsAssessment/monitoringMonitor renal function and serum potassium before and during treatment. If hyperkalaemia is a problem, halve the dose

44、 or stop the treatment.Assessment/monitoringStatins and other lipid lowering agentsStatin treatment is recommended for adults with clinical evidence of CVD and should be offered as soon as possible.Discuss the risks and benefits of treatment with the patient, taking into account comorbidities and li

45、fe expectancy.Start therapy with a drug with a low acquisition cost (taking into account required daily dose and product price per dose).Statins and other lipid loweriFor patients intolerant of statins, other lipid lowering agents should be considered.Reduce or stop the dose of statins if there are

46、issues surrounding the metabolic pathway, food and/or drug interactions and/or concomitant illness.Discontinue the statin and seek specialist advice if patients develop peripheral neuropathy that may be attributable to the statin treatment.For patients intolerant of staAssessment/monitoringMeasure b

47、aseline liver enzymes before initiation.Do not routinely exclude patients who have raised liver enzymes from treatment.Routine monitoring of creatine kinase in asymptomatic patients is not recommended, but should be measured in patients who develop muscle symptoms.Assessment/monitoringPatient Educat

48、ion Education and stress management programmes reduce cardiac mortality and MI recurrence in post MI patients Questions you might like to ask about medicinesHow long will I have to take the medicines for?What is the best time of day to take the medicines?Are there any serious side effects associated

49、 with the medicines?What should I do if I get any side effects?Are there any foods or drinks that I should avoid?What sort of improvements might I expect to notice?How long will it take to notice any effect?Patient Education Educatio藥學監(jiān)護計劃（PHARMACEUTICAL CARE PLAN） 日期Date監(jiān)護點/期望結(jié)果Care Issues /Desired

50、 output 措施 Action 結(jié)果OutputDay1 (09/01) Drug history -ensure the drug history accurately and correctly Check DH-discuss with patient -medical notes-GP/community pharmacistPatient didnt take any drugs on admission Acute treatment on acute myocardial infarction-ensure appropriate acute treatment Check to ensure-aspirin -streptokinase-metoclopramide-b blockerNo contraindication, all drug prescribed and given appropriately 藥學監(jiān)護計劃（PHARMACEUTICAL CARE PLADateCare Issues /Desired output Action OutputSecondary prevention