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1、Assessment of Therapy and Pharmaceutical Care,Pharmaceutical Care,2005/4/20,3,“The responsible provision of drug therapy to achieve definite outcomes that are intended to improve a patients quality of life.”“提供藥事照顧是藥師的責任，以提供直接且負責的藥物治療相關服務為宗旨，且以提升病人生活品質為目標”1993 American Society of Hospital Pharmacist
2、s,藥事照顧及臨床藥學之差異,藥事照顧標準作法,收集與分析患者基本資料分辨目前藥物治療的問題歸納患者的醫療照顧上的需求設定藥物治療之目標訂定藥物治療與監測計劃與其他醫療人員討論及修正藥物治療與監測計劃執行藥物治療計劃監測藥物療效 再修正藥物的治療及修正藥物治療計劃 1996 American Society of Hospital Pharmacists.,2005/4/20,6,重新定義,執業人員需以負責任態度滿足病患與藥物有關的需求，並對提供服務後的結果予以負責藥師照顧病患所有用藥的需求(醫療問題及藥物問題)，不能只單就一種疾病或藥物為問題，因為病人的健康狀況是整體性 Strand 199
3、8,Assessment of Therapy,藥師應具備能力,Knowledge of diseaseTherapeutic planning skillsKnowledge of laboratory and diagnostic testingPhysical assessment skillsKnowledge of drug therapyKnowledge of non-drug therapyDrug information skillsPatient monitoring skillsCommunication skills,2005/4/20,9,Assessment of
4、Therapy,Establishing the patient record(資料建立)Organizing the patient record(整合資料)Systematic approaches to patient therapy assessment(系統性達到評估),2005/4/20,10,Establishing the patient record-1,建立patient record 能提供可得的資訊，進而確定及評估醫療上問題。Direct observations(eg.physical appearance,mental acuity,insulin-injectio
5、n technique)Physical examination(eg.blood pressure,pulse)Laboratory tests(eg.blood glucose,cholesterol levels),2005/4/20,11,Establishing the patient record-2,Knowledge 包含全盤性藥物治療，藥物及疾病的關係，藥物治療 下所預期應有結果。Sources of patient information 成功評估及監測需匯集相關性資訊(獲得subjective data 或是監測 objective physical data)-Data
6、-Rich environment:hospital,long-term care facility-Data-Poor environment:clinician often is required to make assessment with limited information,2005/4/20,12,Establishing the patient record-3,Interviewing the Patient 使用聆聽、肢體語言、音調等技巧及 敘述病史方式溝通-open-ended questions:require patient to explain and elabo
7、rate-close-ended questions:Yes or No,2005/4/20,13,Organizing the patient record-1,提供Pharmaceutical care 應有標準化格式去紀錄病人資訊，病人紀錄(patient record)應涵蓋 the History,Assessment,Plan.Medical History:is essential to the provision of pharmaceutical careDrug History:-Drug identification and use-Assessment of thera
8、peutic response-Assessment of adverse effects-以上方法能快速評估病人使用藥物的情況,2005/4/20,14,Organizing the patient record-2,Social History:病人的生活型態及本身態度通常能決定藥物治療成功或是失敗-Work-Exercise-Diet-Support systems(who else lives with u?dose it ever strain your relationship?)-Attitude,2005/4/20,15,Systematic approaches to pat
9、ient therapy assessment 1,系統性評估病人的治療 Problem-oriented medical record(POMR)approach-Problem list-Subjective and Objective data-Assessment-Plan-Diagnostic Plan-Pharmaceutical Care Plan-Therapeutic Objectives-Patient Education,Elements of the Problem-Oriented Medical Record,SOAP note,Illustration of SO
10、AP,Subjective(Symptoms)-Pt feels-Observing how the pt looks,talks,acts,responds subjective information Objective(Sign)-VS,finding on PE,results of Lab tests,finding of diagnostic procedures(X-ray,CT,ECG)Assessment-Etiology,if therapy is indicated,current therapy and/or new therapyPlan-Therapeutic,dr
11、ugs to be avoided,goals,monitoring(therapeutic&toxic)-Pt education,future plan,2005/4/20,19,SOAP note-1,Problem List-is the table of contents of the medical record and frame wark for patient care（問題點列表是這個病患照護之架構）-all new problems are added to the problem list with sequential numbers（發現的問題點可依序的一一填上）-
12、he most important problem is discussed first(最重要的問題點先討論）-Problems are dynamic：problems are resolved and new problems develop（問題是動態的，解決了一個，又會產生新的問題）-drug-related problems listed by pharmacist(與藥有關之問題點),2005/4/20,20,SOAP note-2,Subjective-Patient complaints of symptoms（病患所抱怨之症狀）-Observations of health
13、 care providers（醫護人員所觀察到資料）datas gathered by talking to the patient or review of system(ROS)（可經由與病患交談或查詢病歷而得）Objective-vital signs（生命徵象數據 BP、HR、RR）-results of laboratory tests（檢驗結果）-results of variews procedures（醫療儀器等檢查之結果）-select the data that necessary to follow drug therapy）（選出需繼續作藥物治療者）,2005/4/2
14、0,21,SOAP note-3,Assessment 1.a problem is drug induced(ADR)?（問題是因藥物副作用所引起的嗎？）2.Whether drug therapy is required?（需要藥物治療嗎？）3.assess the current therapy for appropriateness（評估目前治療之適當性）-Are all the drugs necessary?（所有的藥都需要嗎？）-Is this the drugs of choice for the patient?（是首選藥物?）-Is this the correct dos
15、e?（劑量適當嗎？）-Is this the correct dosage form?（劑型適當嗎？）-Is this the best schedule?（是最好之給藥時間嗎？）-Is the duration of therapy appropriate?（治療期間之長短妥當嗎？）,2005/4/20,22,SOAP note-4,4.is the respones is adequate/expected?（藥效如預期的嗎？）assess the compliance of patients?（評估病人之順服性如何？）5.assess any drug interactions or A
16、DR(occurred or may occur)（評估是否會有或已有藥物交互作用或副作用）The SOAP note should contain all the reasons for any action taken regarding therapy（任何之建議或異議皆應註明理由）Plan(Suggestion)-treatment（治療建議）-monitoring parameters（監測之建議）-endpoints of therapy（治療終點之設定）-patient education（病患教育內容）,Elements of the Problem-Oriented Medi
17、cal Record,Pharmacists Workup of Drug Therapy(PWDT)藥物治療之探討,2005/4/20,25,Pharmacists Workup of Drug Therapy(PWDT),PWDT的焦點特別在於藥物所引起的相關性問題(drug related problem)，有 6 個相關性步驟:establishing patient-specific data-baseidentifying patient-specific,drug-related problemdescribing desired therapeutic outcomeslist
18、ing all therapeutic alternatives that might produce the desired outcomesselecting the drug recommendation that most likely will result in the desired outcomesestablish a plan for therapeutic drug monitoring that documents that desired effect occur and undesired effects are minimized,Pharmacists Work
19、up of Drug Therapy,AssessmentCare plan Follow-up Evaluation,2005/4/20,27,Drug Therapy Assessment-Establishing Priorities-1,-Age and Gender 在小於12歲小孩及大於65歲老人，使用藥物劑量上應考量體重及可能產生藥物清除率不良或會增加藥物敏感性。-Number of Medication Prescribed or Number of Dose per day 研究指出，併用藥物越多種，產生藥物副作用及交互作用機率越高。,2005/4/20,28,Establi
20、shing Priorities-2,-Dose with a High Risk for Adverse Drug Effect or Drug Interaction 1.Within trigger a more in-depth review:eg.Anticoagulants,digoxin,metered-dose inhalers,insulin,or hypoglycemics,aminoglycoside,anticonvulsants.2.With a high potential for triggering drug interations:enzyme inhibit
21、ors and inducers,cimetidine,macrolide antibiotics,fluoroquinolone.-Target Diseases 在特定病人中本身潛藏著疾病，藥物選擇也需考量及持續監測的。,2005/4/20,29,Establishing Priorities-3,-High-Cost Drug 社區藥師當遇到藥物昂貴情況下，應可建議醫師選擇替代藥品。例如:對於 asthma 病人，fluticasone 及 salmeterol 各一支 可建議醫師處方調整為 fluticasone/salmeterol(較便宜且方便使用).-Altered Drug C
22、learance 1.肝，腎功能不全會引響藥物清除率(取決於 肝代謝或腎排除)2.治療指數狹窄:digoxin,phenytoin,vancomycin,2005/4/20,30,Establishing Priorities-4,-Allergy allergy-cross-reacting drugs make medical or pharmacy record-Prescriber Contact 建立於藥師和病人安全、方便及時間允許下-one-on-one consultation-inform for physician(make suggestions for change ca
23、n be made by notes,written in chart,or by formal letters)(國外)-communication with physician(國內),2005/4/20,31,PWDT and SOAP techniques,PWDT for monitoring continuing drug therapySOAP when communicating in writing with other health care providers“The key to both the PWDT and the SOAP techniques is a sy
24、stematic approach to assessing and monitoring drug therapy.”無論是使用SOAP或是PWDT（Pharmacists Workup of Drug Therapy），重要的是經由這個過程能解決臨床上所遇到的問題。,2005/4/20,32,Other SOAP,SOAP(subjective,objective,analysis,plan)originally designed by Dr.Lawrence L.Weed for medical doctors.Expanded-SOAP(add goals,monitoring and
25、 education)SOAPIER(used by nurse)DAR(used by nurse)FARM(finding,assessment,resolution,monitoring)PWDT(Pharmacists workup of drug therapy)PMDRP(Pharmacists Management of Drug-Related Problems)American Society of Health-System Pharmacists PCP(pharmacists care plan)From:A method of documenting pharmace
26、utical care utilizing pharmaceutical diagnosis.Stephen C.Hurley.1998,2005/4/20,33,From:A method of documenting pharmaceutical care utilizing pharmaceutical diagnosis.Stephen C.Hurley.1998,2005/4/20,34,New Modular Format:“PH-MD-ROME”,College of Pharmacy,Idaho State University,Stephen C.Hurley.1998Pat
27、ient Introduction Health ProblemsMedicationsPharmaceutical DiagnosesRecommended OrdersDesired OutcomesMonitoringPatient Counseling and Education,2005/4/20,35,Suggested Pharmaceutical Diagnoses,S.O.A.P.案例研討,2005/4/20,37,Case Presentation-1,S.S.為63歲女性，主訴為過去兩天頭昏、視力模糊，在今日(93/2/8)清晨於浴室昏倒並造成頭部受傷。Medical h
28、istory:stagecolon cancer(4個月前作過切除手術，現以化學治療)，seizure disorder(generalized tonic-clonic)since childhood,但這25年來並無發生，hypertension,近日診斷為憂鬱症(depression)。Physical examination:Wt:58kg,BP:136/85mmHg,pulse:78beats/min,RR:16beats/min,temperature:37.Neurologic exam:she appears to be somnolent with bilateral nys
29、tagmus and ataxic gait.she has a bruise on the left side of the forehead and mild gingival hyperplasia.Laboratory results:unremarkable with normal electrolytes,liver and renal function test,complete blood count.(admission),2005/4/20,38,Case Presentation-2,Dilantin:39.6 mcg/m L,Albumin:4.4 g/d L(STAT
30、)Repeat Dilantin:39.4 mcg/m L(2 hours later)6 months ago,Dilantin:10.5 mcg/m L,2005/4/20,39,Problem List:1.possible phenytoin toxicity2.Head injury3.stagecolon cancer4.Nausea and vomiting5.depression6.hypertension7.seizure disorder8.gingival hyperplasia,Problem-1,possible phenytoin toxicity,2005/4/2
31、0,41,S:1.S.S.head injury resulting from fall secondary to dizziness 2.2-days history of fatigue and blurred vision.3.has not taken any extra doses.Denies use of any OTC medications or other non-prescribed drugs.O:1.Weight:58 kg 2.drug allergy:nil 3.PE:Bruise on left side of forehead;mild gingival hy
32、perplasia,bilateral nystagmus and ataxic gait,otherwise nonfocal neurologic examination;remaining examination WNL.4.Labs:Admission phenytoin concentration:39.6 mcg/m L;Albumin:4.4 g/d L,Repeat level 2 hours later:39.4 mcg/m L.Previous phenytoin concentration on 92/8/8,Dilantin:10.5 mcg/m L.,2005/4/2
33、0,42,Medication:藥名 劑量/用法 time related problem phenytoin(100)3#qhs 2/12/8 P1,P2,P7,P8 hydrochlorothiazide(25)1#qd/am 2/12/8 P6 Prochlorperazine(5)2#Q6h prn 2/12/8 P2,P4 fluoxetine(20)1#qam 2/12/8 P5Chemotherapy Fluorouracil(5-FU)(250)2.8 vial fourth cycle on 2/5 P3 Leucovorin(50)0.7 vial fourth cycle
34、 on 2/5 P3,2005/4/20,43,A:1.S.S.with supratherapeutic phenytoin levels and symptoms consistent with phenytoin toxicity.2.Fluoxetine is a inhibitor of cytochrome P450 2C9 and the temporal relationship between initiation of fluoxetine for depression and the new onset CNS symptoms suggests a possible d
35、rug-drug interaction.Suggestion:1.consider discontinue fluoxetine and temporarily discontinuing phenytoin.,2005/4/20,44,2.Consider citalopram,mitrazapine,or venlafaxine for the treatment of depression.3.Monitoring serum phenytoin every 27 days until concentration falls below 15 mcg/m L and then reinstate phenytoin po 300mg qhs.4.Continue monitoring for further seizure activity,and for dizziness,blurred vision,ataxia,and nystagmus.,
