哮喘和COPD的藥學(xué)監(jiān)護(hù)課件

哮喘和慢性阻塞性肺病

的藥學(xué)監(jiān)護(hù)王卓衛(wèi)生部臨床藥師（師資）培訓(xùn)基地中國人民解放軍臨床藥學(xué)中心第二軍醫(yī)大學(xué)長海醫(yī)院藥學(xué)部哮喘和慢性阻塞性肺病

的藥學(xué)監(jiān)護(hù)王卓衛(wèi)生部臨床藥師（師資1藥學(xué)監(jiān)護(hù)的理解與回顧實(shí)施藥學(xué)監(jiān)護(hù)的標(biāo)準(zhǔn)模式臨床藥師提供的藥學(xué)監(jiān)護(hù)哮喘患者藥學(xué)監(jiān)護(hù)要點(diǎn)COPD患者藥學(xué)監(jiān)護(hù)要點(diǎn)藥學(xué)監(jiān)護(hù)的理解與回顧2藥學(xué)監(jiān)護(hù)的理解與回顧藥學(xué)監(jiān)護(hù)的理解與回顧3pharmaceuticalcare藥學(xué)監(jiān)護(hù)來源于美國，國內(nèi)又稱藥學(xué)服務(wù)。其核心思想是通過藥師與臨床醫(yī)護(hù)人員共同協(xié)作，為病人提供直接負(fù)責(zé)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(biāo)。pharmaceuticalcare藥學(xué)監(jiān)護(hù)來源于美國，國4藥學(xué)服務(wù)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??；②消除或減輕癥狀；③阻止或延緩疾病進(jìn)程；④防止疾病或癥狀的再次發(fā)生。藥學(xué)服務(wù)的目的獲得改善病人生活質(zhì)量的既定結(jié)果。5IntroductionPharmaceuticalCareThedirect,responsibleprovisionofmedication-relatedcareforthepurposeofachievingdefiniteoutcomesthatimproveapatient’squalityoflife(ASHPStatementonPharmaceuticalCare)WhatapharmacistdoestoimprovepatientcareandpatientsafetyIntroductionPharmaceuticalCar6PharmaceuticalCareApatient-centeredpracticePractitionerassumesresponsibilityforapatient’sdrugrelatedneedsPractitionerisheldaccountableforthecareprovidedPharmaceuticalCare7工作開展藥學(xué)監(jiān)護(hù)是藥師在臨床疾病治療中參與并主導(dǎo)的一種工作過程，是多學(xué)科協(xié)作綜合地考慮整體診療計(jì)劃的前提下，從藥學(xué)角度對(duì)治療計(jì)劃進(jìn)行合理的設(shè)計(jì)、執(zhí)行、監(jiān)測和及時(shí)調(diào)整，實(shí)施過程需要患者和醫(yī)護(hù)人員緊密協(xié)作。工作開展藥學(xué)監(jiān)護(hù)是藥師在臨床疾病治療中參與并主導(dǎo)的一種工作過8工作職責(zé)藥師對(duì)治療結(jié)果負(fù)責(zé)至少表現(xiàn)為以下三個(gè)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(shí)際發(fā)生的用藥問題；③防止?jié)撛诘挠盟巻栴}發(fā)生。工作職責(zé)藥師對(duì)治療結(jié)果負(fù)責(zé)至少表現(xiàn)為以下三個(gè)方面：9藥學(xué)監(jiān)護(hù)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(xué)科協(xié)作的臨床服務(wù)藥學(xué)監(jiān)護(hù)是優(yōu)化藥物治療的主要手段藥學(xué)監(jiān)護(hù)是臨床藥師的工作核心藥學(xué)監(jiān)護(hù)與藥物治療藥物治療是臨床治療的主要方式之一10實(shí)施藥學(xué)監(jiān)護(hù)的標(biāo)準(zhǔn)模式ASHPguidelinesonastandardizedmethodforpharmaceuticalcare.AmJHealth-SystPharm.1996;53:1713–6.實(shí)施藥學(xué)監(jiān)護(hù)的標(biāo)準(zhǔn)模式ASHPguidelineson11FunctionsofPharmaceuticalCare?

Collectingandorganizingpatient-specificinformation,?Determiningthepresenceofmedication-therapyproblems,?Summarizingpatients’healthcareneeds,?Specifyingpharmacotherapeuticgoals,?Designingapharmacotherapeuticregimen,?Designingamonitoringplan,?Developingapharmacotherapeuticregimenandcorrespondingmonitoringplanincollaborationwiththepatientandotherhealthprofessionals,?Initiatingthepharmacotherapeuticregimen,?Monitoringtheeffectsofthepharmacotherapeuticregimen,and?Redesigningthepharmacotherapeuticregimenandmonitoringplan.FunctionsofPharmaceuticalCa12CollectingandOrganizingPertinentPatient-SpecificInformationCollectingandOrganizingPert13哮喘和COPD的藥學(xué)監(jiān)護(hù)課件14哮喘和COPD的藥學(xué)監(jiān)護(hù)課件15DeterminingthePresenceofMedication-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.DeterminingthePresenceofMe16SummarizingPatients’HealthCareNeeds.SpecifyingPharmacotherapeuticGoals.DesigningaPharmacotherapeuticRegimen.DesigningaMonitoringPlanforthePharmacotherapeuticRegimen.DevelopingaPharmacotherapeuticRegimenandCorrespondingMonitoringPlan.InitiatingthePharmacotherapeuticRegimen.MonitoringtheEffectsofthePharmacotherapeuticRegimen.RedesigningthePharmacotherapeuticRegimenandMonitoringPlan.SummarizingPatients’HealthC17DevelopingaPharmaceuticalCarePlanStep1.GatheringInformationThepharmacistshouldgatheranaccuratemedicationhistory,includingbothprescriptionandnonprescriptionmedicationsandthereasonsthemedicationswereprescribedortaken.Thepharmacistwilllikelyhavetoobtainsomeinformationfromthephysician,suchaslaboratorytestresultsandhospitalizations.Oncethisinformationiscompiled,thepreparationofaPCP(PharmaceuticalCarePlan)canbegin.DevelopingaPharmaceuticalCa18Step2.IdentifyingProblemsFromthepatient'smedicationprofile,onlyoneproblemisevident:diagnosisofasthma.Ifapplicable,otherproblemshouldalsobelisted.Subjectivefindingsarethosethatthepatientdescribes(e.g.,'Ifeeltiredallthetime,“Ifeelbloated,”or"Iwokeupcoughing").Objectivefindingsarethosethatcanbeobservedormeasuredbythepharmacist(e.g.,patientappearstired,bloodpressureis180/105,pittingedemainankles).Inthepatientwithasthma,thepharmacistwouldhavethepatientuseapeakexpiratoryflowmeterandrecordtheresults.Step2.IdentifyingProblems19Step3.AssessingProblemsThepharmacistanalyzesandintegratestheinformationgatheredinsteps1and2anddrawsconclusionsinpreparationfordevelopingapatient-specificPCP.Forexample,intheasthmacase,thepharmacistmayfirstinvestigatetheetiologyofthefactorsthatexacerbatedtheasthma.Thepharmacistshouldattempttodetermineifdrugs(eg.,aspirin,nonsteroidalanti-inflammatoryagents,orbeta-blockers)causedorexacerbatedtheasthmainthepatient.Thus,theimportanceofanaccurateandcompletedrughistorybecomesevident.Next,thepharmacistassessestheseverityoftheasthma.ThiscouldbeaccomplishedbydeterminingthePEFR,examiningthepatient'sdailysymptomandpeakflowdiary,ordeterminingifthepatienthadbeenhospitalizedandplacedonsteroidsoramechanicalventilator.Step3.AssessingProblems20Step4.DevelopingthePlanThepharmacistestablishesgoalslinkedtoeachofthepatient'sproblemsandspecifiesacourseofactionaimedatmeetingeachgoal.Eachgoal(i.e.,desiredimprovement)shouldbestatedintermsofmeasurableoutcomesthatindicatetheextenttowhichtheparticularproblemhasbeenresolved.Often,thepatienthasseveralproblems,andtheplanmustbecomprehensiveenoughtohaveapositiveeffectontheoverallhealthofthepatient.Step4.DevelopingthePlan21Step5.EvaluatingtheAchievementofOutcomesOutcomesthatwillbeusedtoevaluatethesuccessofthePCPtreatmentplanmustbemeaningful,measurable,andmanageable.Outcomesarespecific,measurableindicatorsforthegoalsoftreatment.Thus,theyshouldbeidentifiedintheplanningprocess.Theoutcomeslistedforasthmawouldinclude,butnotbelimitedto,lowerfrequencyandseverityofacuteexacerbations,fewerphysicianofficevisits,eliminationofsideeffects,PEFRsthatneverfallbelow80%ofpreviouspersonal-bestpredictedrates,feweremergencydepartmentvisits,maintenanceofactivitiesthatenhancethepatient'squalityoflifeandmayhavebeenlimitedbythedisease.Step5.EvaluatingtheAchieve22Documentationshouldincludethesecomponents.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.Documentationshouldincludet23哮喘和COPD的藥學(xué)監(jiān)護(hù)課件24哮喘和COPD的藥學(xué)監(jiān)護(hù)課件25臨床藥師提供的藥學(xué)監(jiān)護(hù)哮喘的藥學(xué)監(jiān)護(hù)COPD的藥學(xué)監(jiān)護(hù)臨床藥師提供的藥學(xué)監(jiān)護(hù)哮喘的藥學(xué)監(jiān)護(hù)26支氣管哮喘診斷流程圖病史典型反復(fù)發(fā)作喘息、氣急、胸悶或咳嗽多與接觸刺激性因素有關(guān)。癥狀可緩解有節(jié)律性波動(dòng)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?jiān)囼?yàn)激發(fā)試驗(yàn)排除其他肺部疾病陽性變異率

正常陰性陽性陰性COPD？支氣管哮喘診斷流程圖病史典型不典型體檢異常無異常肺功能通氣功27哮喘的分級(jí)持續(xù)有癥狀體力活動(dòng)有限每天有癥狀影響活動(dòng)和睡眠每周1次，但<每天1次頻繁≥每周1次>每個(gè)月2次，但<每周1次

60%預(yù)計(jì)值變異率>30%60-80%預(yù)計(jì)值變異率>30%

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

80%預(yù)計(jì)值變異率<20%哮喘的分級(jí)持續(xù)有癥狀每天有癥狀每周1次，頻繁≥每周1次>每個(gè)28哮喘分級(jí)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哮喘分級(jí)用藥建議輕度持續(xù)重度持續(xù)中度持續(xù)舒利迭舒利迭50/229一級(jí)二級(jí)三級(jí)四級(jí)降級(jí)治療間斷發(fā)作輕度持續(xù)中度持續(xù)嚴(yán)重持續(xù)

適級(jí)開始治療哮喘控制至少3個(gè)月降級(jí)治療

哮喘長期治療分級(jí)方案GlobalInitiativeforAsthma(2009)一級(jí)二級(jí)三級(jí)四級(jí)降級(jí)間斷輕30哮喘的管理模式哮喘的管理模式31哮喘管理計(jì)劃教育評(píng)價(jià)和監(jiān)護(hù)哮喘避免誘因急性發(fā)作的治療計(jì)劃規(guī)律隨訪GlobalInitiativeforAsthma建立個(gè)人診治計(jì)劃哮喘管理計(jì)劃教育評(píng)價(jià)和監(jiān)護(hù)哮喘避免誘因急性發(fā)作規(guī)律隨訪Gl32在病區(qū)開展藥學(xué)監(jiān)護(hù)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(hù)要點(diǎn)Carepoints步驟6用藥教育Education步驟7觀察反應(yīng)Monitor步驟8評(píng)估反饋Assessment在病區(qū)開展藥學(xué)監(jiān)護(hù)的一般程序步驟1了解病情33全面了解患者目前病情、治療目標(biāo)和用藥史確認(rèn)藥物選擇、給藥方法安全、適當(dāng)幫助患者優(yōu)化用藥方案制定用藥方案執(zhí)行細(xì)節(jié)用藥過程中加強(qiáng)安全性和有效性觀察的要點(diǎn)及節(jié)點(diǎn)加強(qiáng)患者對(duì)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(yīng)對(duì)現(xiàn)行治療方案進(jìn)行評(píng)估，并進(jìn)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(hù)要點(diǎn)步驟6用藥教育步驟7觀察反應(yīng)步驟8評(píng)估反饋主要目的全面了解患者目前病情、治療目標(biāo)和用藥史確認(rèn)藥物選擇、給藥方法34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(yīng)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?。恢委熌繕?biāo)：理想目標(biāo)和可行目標(biāo)主要矛盾和次要矛盾：輕重緩急步驟1：了解病情病人一般情況：年齡、性別、身高、體重、職業(yè)35疾病情況肺炎：感染部位、范圍、分型、嚴(yán)重程度、病原…支氣管哮喘：分期、分級(jí)…COPD：分期、肺功能分級(jí)、誘因、并發(fā)癥（感染、心衰、呼衰）…肺癌：細(xì)胞分型、分級(jí)、分期…疾病情況肺炎：感染部位、范圍、分型、嚴(yán)重程度、病原…36方式與特點(diǎn)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(guān)的基本情況藥師與患者直接接觸、與醫(yī)護(hù)人員合作方式與特點(diǎn)通過問診、體檢、觀察及閱讀病歷及各類檢查資料，了解37步驟2：審核方案藥物選擇是否適當(dāng)：品種、規(guī)格、劑量、適應(yīng)證、禁忌證；給藥方法是否正確：給藥途徑、給藥時(shí)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(fù)、有無更佳的替代步驟2：審核方案藥物選擇是否適當(dāng)：品種、規(guī)格、劑量、適應(yīng)證、38方式與特點(diǎn)每當(dāng)新開處方或治療方案更改時(shí)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(yīng)與治療利益的相互關(guān)系藥師與醫(yī)生緊密協(xié)作方式與特點(diǎn)每當(dāng)新開處方或治療方案更改時(shí)審核處方，特別要考慮患39步驟3：確定方案確定藥品、聯(lián)合用藥、配伍品種；確定給藥劑量、給藥時(shí)間、療程；確定給藥途徑和方法步驟3：確定方案40方式與特點(diǎn)了解患者的具體情況，并考慮所用藥物的藥代/藥效學(xué)特點(diǎn)，優(yōu)化并確定給藥方案藥師充分發(fā)揮藥學(xué)理論與醫(yī)生合作確定。方式與特點(diǎn)了解患者的具體情況，并考