藥事執(zhí)業(yè)技能：藥物相關(guān)問題之解決-Pharmacy-Practice

1藥事執(zhí)業(yè)技能：藥物相關(guān)問題之解決

PharmacyPracticeSkills:Drug-RelatedProblemsSolving

2課程目的了解systematicclinicaldrugmonitoring的重要性與目的說明SOAPingformat之組成及擷取藥事服務(wù)所需資訊了解patientcasepresentation之結(jié)構(gòu)及順序?qū)W習(xí)以SOAPingformat建立完整的合理用藥評估藉案例學(xué)習(xí)，引導(dǎo)學(xué)生與指導(dǎo)老師充分互動

-重視討論的過程，而非結(jié)果3SystematicClinicalDrugMonitoring的重要性TheresponsibilityofapharmacisttoprovideservicesinaconsistentandcompletemannerThecomplexityofapatient’shealthproblemsThecomprehensiblecommunicationamonghealthcareprofessionals4ThePurposesofSystematicClinicalDrugMonitoringDeterminethatallofapatient’sdrugtherapyisthemostappropriate,mosteffective,safest,andmostconvenientavailable.Identifyanydrugtherapyproblems(DTPs;DRPs)andthegoaloftherapy.Identifyanydrugtherapyproblems(DTPs)thepatientisatriskofdevelopinginthefuturethatistosay,anydrugtherapyproblemsthepharmacistmusthelpthepatienttopreventinthefuture5PharmaceuticalCareProcess6Problem-OrientedApproachIn1964,LawrenceEWeedpublishedtheproblem-orientedapproachtomedicalrecords,patientcare,andmedicaleducation.Asystematic,disciplinedapproachtoeachpatientisusedNo

importanttherapeuticconsiderationsaremissed7Problem-OrientedApproachTwomaincomponentsCompleteproblemlistPhysicalPsychologicalSocial/financialSOAPnotesLogicalthinkingprocess連結(jié)理論和臨床,並應(yīng)用在醫(yī)療照顧OnevisitoneSOAP8POMR

ProblemOrientedMedicalRecordDr.LawrenceWeed提出將病歷制式化的構(gòu)想

POMR=ProblemList(第x項)+各個SOAPProblem1+SOAP1Problem2+SOAP2……ModifiedSOAP

SOA(Problem1,2,…)P(Problem1,2,…)9教學(xué)大綱課程目標(biāo)病歷之基本組成PatientCasePresentationFromdatabasetoplan1.Fromdatabasetoassessment(SOAPnotes)2.Assessment3.Fromassessmenttoplan(Implentation)SOAPingformat案例說明DailySOAPnoteOralcasepresentation10教學(xué)內(nèi)容重點11實際指導(dǎo)學(xué)生實習(xí)-案例討論課程準(zhǔn)備安排課程表-學(xué)習(xí)過程準(zhǔn)備內(nèi)容教材(挑選主題,範(fàn)例,實例,workbook,pharmacotherapy之參考依據(jù))DiseaseManagementCaseDemo(ASHP’s

PharmPrep2001)TerryL.SchwinghammerpharmacotherapyCasebook6thEd.課程分配需多堂課(10幾個小時)漸進地介紹,才能完成1.上課解說2小時2.範(fàn)例說明1小時3.學(xué)生實例演練SOAPingformat及討論

(2小時/次,共5-6次)12病歷之基本組成13病歷之基本組成首頁門診病歷住院病歷急診病歷

14住院病歷病歷摘要(Dischargesummary)醫(yī)囑單(一般/特殊-TPN及C/T)TPRsheetAdmissionnote(內(nèi)科及外科/一般或各?？撇v用紙)Progressnote(SOAPformat)會診記錄治療申請單(X-ray,Cath,RT)檢驗報告(Labdata)監(jiān)測觀察記錄單(GCS,APACHEIIscale)輸入輸出記錄表/膀胱訓(xùn)練記錄表手術(shù)記錄給藥記錄護理評估表/護理記錄出院準(zhǔn)備服務(wù)個案篩選表/收案病患記錄表15MedicationAdministrationRecord

(MAR)RoutineormaitenanceAntibiotics,anticonvulsantsP.R.N.UsuallyarelistedattheendoftheMARFever(if>38.5℃)PainmedicationAntiemeticsSedative-hypnoticagentsStat

(Statim,immediately)Administered

once

andnotrepeatedunlessrecordedGivenassoonaspossiblePrescribedinlife-threateningoremergencysituationsOnetimeorderGivenassoonasconvenientandsometimescanbescheduledaheadoftimeC/T16住院日誌ProgressNote

目的提醒每天病人發(fā)生了什麼事以及醫(yī)師目前的想法精神-忠實記錄,簡短(縮寫),清晰易讀,遵守常用習(xí)慣

重要性對病患病程的演進，客觀的變化，醫(yī)師的判斷，臨床的因應(yīng)做一個重要的記錄對病患而言，這是他的”傳記”，是他一生最重要的記錄對醫(yī)師而言，這是他訓(xùn)練過程的”事證”，對自己的想法與做法留下記錄;也是醫(yī)師間溝通的工具對醫(yī)療而言，是醫(yī)療的重點記錄，是疾病處理的基本依據(jù)，是繼續(xù)醫(yī)療的重要參考對醫(yī)學(xué)而言，是人類醫(yī)學(xué)的重要資產(chǎn)，是醫(yī)學(xué)進步重要文獻格式-SOAPformat17常用縮寫一般身體評估(身體診察)疾病診斷藥品及其用法檢查名稱18推薦讀物(入門)醫(yī)護專用縮寫辭典(杜武志主編)取材範(fàn)圍廣泛醫(yī),牙,藥,護,檢驗,管理疾病診斷,理學(xué)檢查,名稱,病歷用語臺大內(nèi)科住院醫(yī)師醫(yī)療手冊(楊汾池總編)一般內(nèi)科訓(xùn)練(primarycaretraining)綜論(醫(yī)療實務(wù)要點,各病房特殊檢查及術(shù)後照顧)各論(CV,GI,Nephro,Chest,Endo,Neuro,Rheuma,ID,Hema,Oncology)TheWashingtonManualofMedicalTherapeutics31ed.Clinicalskillsforpharmacists,Apatient-focusedapproach.2ndEd.KarenJ.Tietze,Mosby19PatientCasePresentationTheacceptedtoolfordocumentingandcommunicatingpatientinformation(suggestedbyTietze,K.J.)20Components

ofthePatientCasePresentationGeneralinformationChiefcomplaint(CC)Historyofpresentillness(HPI)Pastmedicalhistory(PMH)Medicationhistory(MedHx)Familyhistory(FH)Socialhistory(SH)Reviewofsystems(ROS)Physicalexamination(PE)Pertinentpositiveandnegativelaboratoryanddiagnostictestresults(Labs)

P’tproblemlistandinitialplansP’tprogressDischargedataFinaldiagnosisDischargemedicationsPlansforfollow-up21SuggestedSequenceforPresentationofInformationGeneralinformation(Gen)

↓Chiefcomplaint(CC)

↓Historyofpresentillness(HPI)

↓Pastmedicalhistory(PMH)

↓Socialhistory(SH)↓Familyhistory(FH)

↓Medicationhistory(MedHx)↓↓Reviewofsystems(ROS)

↓Physicalexamination(PE)

↓Laboratoryanddiagnostictestresults(Lab)

↓Problemlistandinitialplans

(SOAPformat)

↓P’tprogresstodate

(SOAPformat)22FromdatabasetoplanStepsofSystematicClinicalDrugMonitoring(suggestedbyShaoC,Chiang,Pharm.D.,R.Ph.)23ProblemConversion

Medicalproblems(Dx)

Medicationproblems(Drugtherapyproblems

)24FromDatabasetoPlan1.FromdatabasetoassessmentSOAPnotes2.Assessment3.Fromassessmenttoplan(Implentation)Therapeuticsplanning-pharmacistDiagnosticTherapeutic(Prescription)Educational(p’t)Monitoring251.Fromdatabaseto

assessment(SOAPnotes)Atadmission(newp’t)26SOAPingProblemlistnumberedacuity/priorityResolved/inactiveDatabaseCCHPIPMHFHSHMedHxComplianceAllergiesROSPELabtestsX-rayScansProcedureSOAPnotesSOAPnotesImplementationofplandiagnostictherapeuticeducational(p’t)Follow-upofprogress272.Assessment

Atadmission(newp’t)28InterprettheFindingsinTermsoftheProbableProcessPathologicalprocessCongenital/InflammatoryImmunological/NeoplasticMetabolic/NutritionalDegenerative/VascularTraumatic/ToxicPathophysiologicalPsychopathophysiologicalDrug-related29MakeOneorMoreHypothesesabouttheNatureofthePatient’sProblem

Selectthemostspecificandcentralfindingsaroundwhichtoconstructyourhypothesis.Matchyourfindingsagainstalltheconditionsyouknowthatcanproducethem.Eliminatethediagnosticpossibilitiesthatfailtoexplainthefindings.Weighthecompetingpossibilitiesandselectthemostlikelydiagnosisfromamongtheconditionsthatmightberesponsibleforthepatient’sfindingsGivespecialattentiontopotentiallylife-threateningandtreatableconditions303.Fromassessmenttoplan

(Implentation)

Therapeuticsplanning

Atadmission(newp’t)31ComponentsofTherapeuticsPlanning*Regimens-initial&alternative32ThePlanningProcessProblemidentificationIdentificationofsubjective

and

objectiveparametersGroupingofrelatedparametersAssessmentoftheparametersanddeterminationofspecificp’tproblemsProblemprioritization:IdentifyactiveandacuteproblemsSelectionofspecifictherapeuticregimensCreationofalistoftherapeuticoptionsEliminationofdrugsfromthelistbasedonp’t-specificandexternalfactorsSelectionofdosage,route,anddurationoftherapyIdentificationofalternativetherapeuticregimensCreationofamonitoring

planMonitoringandmodificationoftheregimensasnecessary33AnxietyBloatingBlood-tingedsputumBlurredvisionBreasttendernessChillsColdintoleranceConfusionConstipationCrampsDecreasedappetiteDepressionDiarrheaDifficultyconcentratingDryskinDysuriaFatigueFlatulenceHeadacheHeartburnHeatintoleranceImpotenceIndigestionInsomniaItchingJointpainLossofappetiteLossoflibidoMuscleachesMuscleweaknessNasalcongestionNasalitchingNauseaNervousnessNumbnessPainPalpitationsPoundingpulseRashSeizuresShortnessofbreathSlurredspeechSneezingSorethroatSyncopeThirstTinglingTinnitusTremorVertigoWeaknessWheezingCommonSubjectiveParameters34BHandBWVitalsignsBT,BP,HR,RRBloodchemistriesNa,K,Cl,CO2,Glu,Scr,AST,ALT,Bil,Ca,Mg,CHL,TG,Alk-P,LDH,UA,BUNBloodgasespH,Pco2,Pco2,HCO3-BloodproteinTotalprotein,albumin,complements,immunoglobulinsHematolog

Hb,Hct,MCV,MCH,MCHC,RBC,WBCDCUrinalysisSp.gr,cellularcontent,proteinCulturesandsensitivitesBlood,urine,sputum,tissueSerumbloodconcentrationsSpecificorgansystemtestsPEFR,FEV1,FVC,FEV1/FVC,EF,T3,T4,TSH,ClcrMiscellaneousU/O,abdgirth,no.ofloosestools/day,I/OCommonObjectiveParameters35FactorstoConsiderwhenSelectingaSpecificTherapeuticRegimenPatient-specificfactorsWhatregimenshaveeffectively

managedtheprobleminthepast？Whatregimenshavenoteffectivelymanagedtheprobleminthepast？Howmightotherpatientproblemsinfluencetheproposedregimen？Howmighttheproposedregimeninfluenceotherpatientproblems？ExternalfactorsCurrent“stateoftheart”therapeuticsCostoftheproposedtherapvFormularylimitations36GuidelinesforAlteringInitialDrugTherapyIftheregimenisineffective,changethedrugifthefollowingaretrueThepatientreceivedanadequatetrialofthedrugThepatientreceivedanadequatedosageofthedrugThepatientiscompliantIftheregimenisassociatedwithlife-threatening

sideeffects,discontinuethedrugIfthepatientisnotcomplyingwithregimenbecauseofunacceptablesideeffects,discontinuethedrugIfthepatienthasnon-life-threateningsideeffectsandiswillingtocontinuethedrug,minimizethesideeffectsbydoingthefollowing:AdjustthedosageofthedrugChangethetimingofthedose373.Fromassessmenttoplan

(Implentation)

MonitoringAtadmission(newp’t)38Patient-FocusedCareCycle

ANever-EndingCycle

DataacquisitionandassessmentProblemidentificationandprioritizationTherapeuticplanningPatientmonitoring39TheProcessofMonitoringTherapeuticRegimensSettherapeuticgoalsDeterminepatient-anddrug-specificmonitoringparametersIntegrate

themonitoringplanObtaindataAssesstheresponsetotherapyAlterthetherapeuticregimenifnecessaryRepeatStep1-640OrganizationofMonitoringParameters

(TheFour-SquareMethod)Subjective-TherapeuticSubjective-Toxicexpectedtherapeuticoutcomeindicatingtherapeuticfailureor

harmObjective-TherapeuticObjective-Toxicexpectedtherapeuticoutcomeindicatingtherapeuticfailureor

harm41StepsofsystematicclinicaldrugmonitoringatinpatientsettingHospitalstay(oldp’t)42HospitalStayDailySOAPnoteEachproblemhasitsownSOAPnote.Thesubjectiveandobjectivedatashouldincludethevaluesofdrugmonitoringparameters.Allproblemsshouldbeassessedandplaned,unlesstheproblemhasbeenresolvedDailydrugmonitoring43RealPracticeSettingWithtimeandpractice,theprocessofassessingpatienttherapyandprioritizingtheneedtomakeaninterventionbecomessecondnatureanddoesnotrequireaconcertedefforttomentallycheckoffeachstepafterithasbeenperformed.Settingpriorityaboutwhichpatientsrequiremorein-depthintervention.44SOAPingformat45SOAPingFormatSOAPingTheprocess

ofidentifyingthesubjectiveandobjectivedata,assessingtheproblem,anddevelopingaspecifictherapeuticandmonitoringplanAformalorganizationlstructureStepsCreationofalistofrelatedsubjectiveparametersCreationofalistofrelatedobjectiveparametersAssessmentanddocumentationoftheproblemDocumentationofthetherapeuticplanforaddressingtheproblem46ThinkingProcessTipsProblemidentificationDesiredoutcomeTherapeuticalternativesOptimalplanOutcomeevaluationPatienteducation47ProblemListCurrentmedicalproblemsGoaloftherapyMeasurableendpoint48SOAPingFormat

USCSchoolofPharmacyKathleenBesinque

PharmD,MSEd.)49CurrentDrug-TherapyProblemsSubjectiveandObjectiveProblem

(subjectiveandobjective)CurrentmedicationS:

CC:PertinentmedicalHx:(HPI/PMH)ROS:SH:FH:Allergies:ADR:DrugsOTCsHerbalO:(PE/Labs)

50CurrentDrug-TherapyProblemsAssessmentEtiology(orriskfactors)Evaluateneedfortherapy;evaluatecurrenttherapy(Evidenceneedfortherapyevaluation)Drugtherapyproblem1CPG1ClassofdrugsDrugtherapyproblem2CPG2ClassofdrugsDrugtherapyproblem3CGP3Classofdrugs51CurrentDrug-TherapyProblemsPlanRecommendeddrugtreatment,drugtoberevised,furthertestGoalandmonitoringparameters(toxicandtherapeutic)PatienteducationRecommend1ItemofdrugsGoal1TherapeuticToxicEducation1Recommend2ItemofdrugsGoal2TherapeuticToxicEducation2Recommend3ItemofdrugsGoal3TherapeuticToxicEducation352ProblemConversion

Medicalproblems(Dx)

Medicationproblems(Drugtherapyproblems)53教學(xué)時遭遇的困難與處理54教學(xué)時遭遇的困難與處理(1)藥師指導(dǎo)clinicaldrugmonitoring及casepresentation之技巧有差異參與醫(yī)院藥學(xué)實習(xí)指導(dǎo)師資認(rèn)證訓(xùn)練課程閱讀病歷抓不到(困難擷取)藥事服務(wù)所需資訊Medicalproblem(Dx)Medicationproblems(Drugtherapyproblems)病歷上少有藥師的記錄或看到dailySOAPnote持續(xù)練習(xí)就能習(xí)慣如何釣魚需由作中去領(lǐng)悟55教學(xué)時遭遇的困難與處理(2)教學(xué)過程多是由指導(dǎo)藥師來告訴答案藥師在藥事服務(wù)介入的時間多於學(xué)生報告時間的壓力學(xué)生常是事到臨頭才要做學(xué)生難於確認(rèn)那麼多Drugtherapyproblems臨床教學(xué)模式常是糾正學(xué)生的錯誤,解釋處理Drugtherapyproblems的原則已修過藥物治療學(xué)/臨床藥學(xué)課程者再實習(xí)病案報告非concurrentcase藥師需作調(diào)劑工作藥師未全程參與病患照護難了解醫(yī)師對藥師意見的接受度及藥師建議的可行性56結(jié)論Problemorienteddrugmonitoring有清晰的邏輯思考可解決複雜的Drugtherapyproblems本課程是建立思考邏輯沒有絕對標(biāo)準(zhǔn)的答案引導(dǎo)學(xué)生/藥師的指導(dǎo)藥師-很重要57CaseExample(案例說明)

Hypertension58課程目標(biāo)(HTN)EstablishgoalsforthetreatmentofHTN.Chooseappropriatelifestylemodificationsandanti-HTNbasedonpatient-specificcharacteristisandconcurrentdiseasestates.Designappropriatemonitoringplansforptsreceivinganti-HTNtherapy,includinglaboratoryparametersandtimeintervals.ModifypharmacotherapeuticregimensforptswhoexperienceadverseeventsordonothaveadequateBPreductiononaninitialregimen.Provideappropriatepatienteducationforanti-HTNregimens.59PatientGeneralInformation(Gen)

病患基本資料Patientname:王先生Chartno:xxxxxxxx(Bedno:xxxx-x)Address:臺南市信義路Age:79Height:175cmSex:MMarriagestatus:marriedWeight:95.4kgAllergies:NKDADateofadmission(DOA):yymmdd60ChiefComplaint(CC)

病患主訴病情王先生is79-yomaleseenintheEDwithrespiratorydistresswithseveredyspneaandwheezing.61HistoryofPresentIllness(HPI)

發(fā)生現(xiàn)在疾病之病程王先生wascominghomefromthegrocerystorewhenhebecameshortofbreathandwheezingcarryinginhisgroceries.Hecouldonlysayacouplewordsbetweenbreaths.Hisneighbornoticedhimindistressandcalled911.王先生experiencedsevereshortnessofbreath6monthsagoandwashospitalizedforacutesevereasthma.62PastMedicalHistory(PMH)

過去病史Diagnosiswithasthmaapproximately20yearsago,rheumatoidarthritisabout5yearsago,andbenignprostatichyperplasialastyear.Patientusingaherbalproducttotreathisbenignprostatichyperplasia.Admittedtohospital3timesinthepast2yearsforexacerbationofasthma.Previousofficevisit5weeksago,documentedabloodpressurereadingof150/95mmHg.63SocialHistory(SH)

個人生活史Tobaccouse:1/2pack/weekAlcoholuse:SixpackperweekCaffeineuse:2Cupsofcoffeeeverymorning64FamilyHistory(FH)

家族病史MotherdiedofanMIatage68.Fatherdiedoflungcanceratage75.65MedicationRecord(PrescriptionandOTC)(MedHx)用藥史Furosemide40mgpoqAMAlbuterolinhaler2puffsqid

prnBeclomethasoneinhaler1puffqidIbuprofen800mgpo

tidHerbalproductwithlicoricepo

qdAcetaminophenpo

prn66ReviewofSystems(ROS)

現(xiàn)有疾病或問題(HPI除外)Wheezingandcoughing67PhysicalExamination(PE)

身體診察VS:BP160/100mmHgHR120beats/minRR31rpmT38.5℃Ht175cmBW95.4kgBMI31.2(95.4/1.75x1.75)CHEST:Expiratorywheezes68LaboratoryandDiagnosticTests(Labs)

檢驗數(shù)據(jù)及檢查報告Potassium3.8mEq/LSodium145mEq/LSerumcreatinine1mg/dLFBG100mg/dLTotalcholesterol200mg/dLHDL35mg/dLRBC4.7cells/mm3Hgb15g/dLHct44%PH7.40PaO255mmHgPaCO240mmHg69Diagnosis

診斷Primary:1)Asthma2)HypertensionSecondary:1)Benignprostatichyperplasia2)RheumatoidarthritisProblemlist70ProblemListCurrentmedicalproblemsGoaloftherapyMeasurableendpointPrimary:1)AsthmaSymptomcontrolPreventasthmaepisodesorattacksPEFRNoDOE,SOB,PND2)HypertensionPreventCHD,StrokeandNephropathyBPSecondary:1)BPHSymptomcontrolDRE(digitalrectalexam)UFR(urineflowrate)2)RAImproveQOLArrestorretarddiseaseprogressSwollen&tenderjointsRF,ESR,ANA,CBCX-Ray71CurrentDrug-TherapyProblemsSubjectiveandObjectiveProblem

(subjectiveandobjective)CurrentmedicationS:

PertinentmedicalHx:Asthmax20yrs;RAx5yrs;BPHx1yrago;HTNx5wksROS:respiratorydistresswithseveredyspnea;wheezingandcoughingTobaccouse:0.5pack/week;alcoholuse:6pack/week;caffeineuse:2cupsofcoffeeeverymorningUseaherbalproducttotreathisBPHFurosemide40mgpoqAMAlbuterolinhaler2puffsqid

prnBeclomethasoneinhaler1puffqidIbuprofen800mgpo

tidHerbalproductwithlicoricepo

qdAcetaminophenpo

prnO:175cm,95.4kgHR:120BP:160/100RR:31T38.5℃ExpiratorywheezesPH7.40;PaO255;PaCO240Admittedtohospital3times/past2yrsforAEofasthmaBP150/95mmHgpreviousofficevisit5wksago72CurrentDrug-TherapyProblemsAssessmentEtiology(orriskfactors)Evaluateneedfortherapy;evaluatecurrenttherapy(Evidenceneedfortherapyevaluation)AEofasthmaPrimarytherapiesforAE(mostsafelyundertakeninahospitalorhospital-basedER)Repetitiveadministrationofrapid-actinginhaledβ2-agonistEarlyintroductionofsystemicglucocorticosteroidsOxygensupplementationCloselymonitorresponsetotreatmentwithserialmeasuresoflungfunctionInadequateresponsetotreatmentforHTND/Cherbalproductwithlicorice(hasbeenshowntohaveanaldosterone-likeaction)BothibuprofenandlicoricecancauseaninadequateresponsetoHTNtherapyIfBPremainselevated,theclinicianshouldconsiderinitiatinganα-blockerInadequateBPHtreatmentThepreferredtherapyforthisptmaybeα-blockers(thefavorableeffectsonprostatismanddyslipidemia-decreaseLDL-CandincreaseHDL-CPosturalhypotensioniscommonlyexperiencedwithα-1blo