哮喘和COPD的藥學監(jiān)護課件

哮喘和慢性阻塞性肺病

的藥學監(jiān)護王卓衛(wèi)生部臨床藥師（師資）培訓基地中國人民解放軍臨床藥學中心第二軍醫(yī)大學長海醫(yī)院藥學部藥學監(jiān)護的理解與回顧實施藥學監(jiān)護的標準模式臨床藥師提供的藥學監(jiān)護哮喘患者藥學監(jiān)護要點COPD患者藥學監(jiān)護要點藥學監(jiān)護的理解與回顧pharmaceuticalcare藥學監(jiān)護來源于美國，國內(nèi)又稱藥學服務。其核心思想是通過藥師與臨床醫(yī)護人員共同協(xié)作，為病人提供直接負責的藥物治療，并積極監(jiān)測治療的全過程，以改善病人的治療效果，最終提高病人的生活質(zhì)量為目標。藥學服務的目的獲得改善病人生活質(zhì)量的既定結(jié)果。包括：①治愈疾病；②消除或減輕癥狀；③阻止或延緩疾病進程；④防止疾病或癥狀的再次發(fā)生。IntroductionPharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatient’squalityoflife(ASHPStatementonPharmaceuticalCare)WhatapharmacistdoestoimprovepatientcareandpatientsafetyPharmaceuticalCareApatient-centeredpracticePractitionerassumesresponsibilityforapatient’sdrugrelatedneedsPractitionerisheldaccountableforthecareprovided工作開展藥學監(jiān)護是藥師在臨床疾病治療中參與并主導的一種工作過程，是多學科協(xié)作綜合地考慮整體診療計劃的前提下，從藥學角度對治療計劃進行合理的設計、執(zhí)行、監(jiān)測和及時調(diào)整，實施過程需要患者和醫(yī)護人員緊密協(xié)作。工作職責藥師對治療結(jié)果負責至少表現(xiàn)為以下三個方面：①發(fā)現(xiàn)潛在的或?qū)嶋H存在的用藥問題；②解決實際發(fā)生的用藥問題；③防止?jié)撛诘挠盟巻栴}發(fā)生。藥學監(jiān)護與藥物治療藥物治療是臨床治療的主要方式之一藥物治療是多學科協(xié)作的臨床服務藥學監(jiān)護是優(yōu)化藥物治療的主要手段藥學監(jiān)護是臨床藥師的工作核心實施藥學監(jiān)護的標準模式ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:1713–6.FunctionsofPharmaceuticalCare?

Collectingandorganizingpatient-specificinformation,?Determiningthepresenceofmedication-therapyproblems,?Summarizingpatients’healthcareneeds,?Specifyingpharmacotherapeuticgoals,?Designingapharmacotherapeuticregimen,?Designingamonitoringplan,?Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,?Initiatingthepharmacotherapeuticregimen,?Monitoringtheeffectsofthepharmacotherapeuticregimen,and?Redesigningthepharmacotherapeuticregimenandmonitoringplan.CollectingandOrganizingPertinentPatient-SpecificInformationDeterminingthePresenceofMedication-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.SummarizingPatients’HealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.DevelopingaPharmaceuticalCarePlanStep1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.Step2.IdentifyingProblemsFromthepatient'smedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,'Ifeeltiredallthetime,“Ifeelbloated,”or"Iwokeupcoughing").Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.Step3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatient'sdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.Step4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatient'sproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.Step5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatient'squalityoflifeandmayhavebeenlimitedbythedisease.Documentationshouldincludethesecomponents.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.臨床藥師提供的藥學監(jiān)護哮喘的藥學監(jiān)護COPD的藥學監(jiān)護支氣管哮喘診斷流程圖病史典型反復發(fā)作喘息、氣急、胸悶或咳嗽多與接觸刺激性因素有關。癥狀可緩解有節(jié)律性波動規(guī)律不典型體檢異常哮鳴音呼氣相延長無異常發(fā)現(xiàn)肺功能通氣功能PEF監(jiān)測阻塞性障礙正常舒張試驗激發(fā)試驗排除其他肺部疾病陽性變異率

正常陰性陽性陰性COPD？哮喘的分級持續(xù)有癥狀體力活動有限每天有癥狀影響活動和睡眠每周1次，但<每天1次頻繁≥每周1次>每個月2次，但<每周1次

60%預計值變異率>30%60-80%預計值變異率>30%

80%預計值變異率20-30%治療前哮喘病情嚴重程度分級癥狀夜間癥狀FEV1或峰流速重度持續(xù)（第4級）中度持續(xù)（第3級）輕度持續(xù)（第2級）間歇狀態(tài)（第1級）<每周1次，發(fā)作間歇無癥狀GINA2010≤每個月2次

80%預計值變異率<20%哮喘分級用藥建議輕度持續(xù)重度持續(xù)中度持續(xù)舒利迭50/100bid-50/250bid舒利迭50/250bid間歇發(fā)作輔舒酮125必可酮?250或1噴qd輔舒酮125必可酮?250或1噴,bidICS+LABA萬托林按需使用輔舒酮?125必可酮?250＋或1-2噴,qd若控制不好，此建議僅供參考，具體詳見GINA2002一級二級三級四級降級治療間斷發(fā)作輕度持續(xù)中度持續(xù)嚴重持續(xù)

適級開始治療哮喘控制至少3個月降級治療

哮喘長期治療分級方案GlobalInitiativeforAsthma(2009)哮喘的管理模式哮喘管理計劃教育評價和監(jiān)護哮喘避免誘因急性發(fā)作的治療計劃規(guī)律隨訪GlobalInitiativeforAsthma建立個人診治計劃在病區(qū)開展藥學監(jiān)護的一般程序步驟1了解病情Patient步驟2審核方案Review步驟3確定方案Decision步驟4方案注釋Annotation步驟5監(jiān)護要點Carepoints步驟6用藥教育Education步驟7觀察反應Monitor步驟8評估反饋Assessment全面了解患者目前病情、治療目標和用藥史確認藥物選擇、給藥方法安全、適當幫助患者優(yōu)化用藥方案制定用藥方案執(zhí)行細節(jié)用藥過程中加強安全性和有效性觀察的要點及節(jié)點加強患者對醫(yī)囑的理解和正確執(zhí)行，提高依從性和療效觀察藥物治療的效果和各種不良反應對現(xiàn)行治療方案進行評估，并進一步優(yōu)化步驟1了解病情步驟2審核方案步驟3確定方案步驟4方案注釋步驟5監(jiān)護要點步驟6用藥教育步驟7觀察反應步驟8評估反饋主要目的步驟1：了解病情病人一般情況：年齡、性別、身高、體重、職業(yè)等；特殊病理生理：老年、兒童、哺乳、妊娠；肝、腎功能、特殊用藥史、藥物不良反應史；疾病情況：病變部位、范圍、病因、誘因；疾病分型、分期、分度；并發(fā)癥、并存疾??；治療目標：理想目標和可行目標主要矛盾和次要矛盾：輕重緩急疾病情況肺炎：感染部位、范圍、分型、嚴重程度、病原…支氣管哮喘：分期、分級…COPD：分期、肺功能分級、誘因、并發(fā)癥（感染、心衰、呼衰）…肺癌：細胞分型、分級、分期…方式與特點通過問診、體檢、觀察及閱讀病歷及各類檢查資料，了解與藥療有關的基本情況藥師與患者直接接觸、與醫(yī)護人員合作步驟2：審核方案藥物選擇是否適當：品種、規(guī)格、劑量、適應證、禁忌證；給藥方法是否正確：給藥途徑、給藥時間、給藥療程、配伍情況、聯(lián)用情況；是否還有優(yōu)化可能：有無遺漏、有無重復、有無更佳的替代方式與特點每當新開處方或治療方案更改時審核處方，特別要考慮患者的病理、生理狀況及合并用藥之間的相互作用，考慮藥物的不良反應與治療利益的相互關