透過實地訪視之方式關懷民眾用藥問題 ·...

透過實地訪視之方式關懷民眾用藥問題

署立台南醫院呂美瑩藥師

99.03.26

Definition of Pharmaceutical Care

□ Pharmaceutical care is the responsibleprovision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. These outcomes are:

1. Cure of a disease.2. Elimination or reduction of a patient’s

symptomatology.3. Arresting or slowing of a disease process.4. Preventing a disease or symptomatology.

Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.

□ At the heart it means caring about the patient, and as a health care professional spending the time and effort needed to help another human being.

□ To do this successfully, the pharmacist needs to apply skills and knowledge beyond that required for traditional dispensing-oriented pharmacy practice.

Pharmaceutical Care

Clinical skills for pharmacists

病人照顧

疾病相關知識

藥品治療知識非藥品治療的知識

檢驗和診斷檢查的知識

溝通技巧

病人監測技巧身體評估技巧

藥品資訊技巧

治療計畫技巧

The Therapeutic Relationship

□ A key concept in the delivery of pharmaceutical care is the direct responsibility the pharmacist has to the patient.

□ Patients need to be actively involved in their health care, and it is essential that develop a trusting and collaborativerelationship with health care providers.

Five steps in the Pharmaceutical Care Process

1. A professional relationship with the patient must be established.

2. Patient-specific medical information must be collected, organized, recorded, and maintained.

3. Patient-specific medical information must be evaluated and a drug therapy plan developed mutually with the patient.

4. The pharmacist must ensure that the patient has all supplies, information, and knowledge necessary to carry out the drug therapy plan.

5. The pharmacist must review, monitor, and modify the therapeutic plan as necessary and appropriate, in concert with the patient and health care team.

Medication problem checklist□ Medications without medical indications.□ Medical conditions for which there are no

medications prescribed.□ Medications prescribed inappropriately for a

particular medical condition.□ Inappropriate medication dose, dosage form,

schedule, route of administration or method of administration.

□ Therapeutic duplication.□ Prescribing of medications to which the patient is

allergic.□ Actual and potential ADEs.

Medication problem checklist□ Actual and potential adverse clinically

significant drug-drug, drug-disease, drug-nutrient and drug-laboratory test interactions.

□ Interference with medical therapy by social or recreational drug use.

□ Failure to receive the full benefit of prescribed medication therapy.

□ Problems arising from the financial impact of medication therapy on the patient.

□ Lack of understanding of the medication therapy by the patient.

□ Failure of the patient to adhere to the medication regimen.

PRIME pharmacotherapy problem types

□Pharmaceutical□Risks to patients□ Interactions□Mismatch between medications

and indications/conditions□Efficacy issues

□Pharmaceutical- assess for incorrect factors, as follows:

■ Dosage■ Form■ Route■ Timing■ Duration■ Frequency

PRIME pharmacotherapy problem typesPRIME pharmacotherapy problem types

□Risks to patients- assess for risks, as follows:

■ Known contraindication■ Medication allergy■ Drug-induced problem■ Improper use (ie risk if misused)■ Common/serious ADEs■ Medication-error considerations


□ Interactions-assess for the following:

■ Drug-drug■ Drug-disease/condition■ Drug-food■ Drug-laboratory test


□Mismatch between medications and indications/conditions-assess for the following:

■ Medication used without indication■ Indications/condition untreated


□ Efficacy issues-assess for the following:

■ Suboptimal selection of pharmacotherapy for indications■ Minimal or no evidence of therapeutic effectiveness■ Suboptimal pharmacotherapy (taking/receiving

medications incorrectly)-eg patient preference considerations (undesirable prior experiences with medications or, does not believe it works)

■ Medications availability considerations (eg no access to medications)

■ Compliance/administration considerations (eg inability to pay or unable to administer correctly or at all).


PMR(Patient medical record)

□ Primary purpose is to convey information for use in patient care; it serves as a tool for communication among health care professionals.

□ PMR may also be used inLegal proceedings (e.g., as evidence)Education (e.g., for training students)Research (e.g., for evaluating clinical drug use)Quality assurance evaluations (e.g.,to ascertain adherence to practice standards)

□ CQI (Continuous quality improvement)Am J Health-Syst Pharm. 1992:38-41.


□ A summary of the patient’s medication history on admission, including medication allergies and their manifestations.

□ Oral and written consultations provided to other health care professionals regarding the patient’s drug therapy selection and management.

□ Physicians’ oral orders received directly by the pharmacist.□ Clarification of drug orders.□ Adjustments made to drug dosage, dosage frequency, dosage

form, or route of administration.□ Drugs, including investigational drugs, administered.□ Actual and potential drug-related problems that warrant

surveillance.□ Drug-related patient education and counseling provided.

Am J Health-Syst Pharm. 1992:38-41.


□ Drug therapy-monitoring findings, including□ The therapeutic appropriateness of the patient’s drug regimen,

including the route and method of administration.□ Therapeutic duplication in the patient’s drug regimen.□ The degree of patient compliance with the prescribed drug

regimen.□ Actual and potential drug-drug, drug-food, drug-laboratory test,

and drug-disease interactions.□ Clinical and pharmacokinetic laboratory data pertinent to the

drug regimen.□ Actual and potential drug toxicity and adverse effects.□ Physical signs and clinical symptoms relevant to the patient’s

drug therapy.

Am J Health-Syst Pharm. 1992:38-41.

Applying Clinical Skills in Hospitals

□Central pharmacy□Clinical services□Nursing unit□Full-time clinicians

Decentralized hospital pharmacists

實地訪視

□一般病房跟診查房、病患訪視

□急重症病房病患訪視

□出院準備服務病患訪視

□護理之家病患訪視

□居家病患訪視

出院準備服務病患訪視

Helpful factors□ A pharmacist who monitors drug therapy has

multiple opportunities to work directly with patients, nurses, and physicians to provide pharmaceutical care.

□ As he screens patient’s profiles and identifies potential issues related to drug safety or efficacy, he can discuss matters directly with the patient to obtain additional patient data and evaluate if one or more drug therapy problems is present.

□ Because little chart information is specifically drug-related, pharmacists must often gather additional information from the patient in order to identify drug therapy problems.

□ Family members are especially valuable resources for patients who cannot speak for themselves due to either illness or age.

Helpful factors

Challenge□ Most patients are only in the hospital for 3

or 4 days. □ Pharmacists may need to develop

screening tools or other qualifying mechanisms to determine which patientsshould receive a pharmaceutical care work-up.

病人選擇

□須藥品指導之病人-如氣喘病人-吸入劑使用

□特殊病人群-如高血壓、冠心病、心肌梗塞、鬱血性心臟衰竭、糖尿病患者。

□服用特定藥品的患者-如服用warfarin的病人

□超過特定年齡的患者-如超過75歲的病人

□兒童患者

□出院病人

出院準備服務

□病人ㄧ入住院，即評估病人及家屬需求，經由專業人員提供出院後的照護服務，讓病患順利由醫療機構轉至另一個照護環境，以提升病人持續性照護及家屬生活品質與滿意度。

出院準備服務內容

□1.教導照顧技巧。

□2.出院用藥、復健、營養諮詢與指導。

□3.社會福利、醫療資源諮詢與轉介。

□4.輔助器材租借與購買資訊。

□5.安排合適居家護理。

□7.協助轉介適合長期照顧機構。

□8.出院後電話追蹤。

出院準備服務委員會：院長為主任委員，副院長為召集人

內、外、產科收案篩選條件

收案標準（1）內科：篩選分數大於5分即個案。

（2）產科：篩選四條件，只要符合一項即收案。

（3）精神科：

a.篩選分數大於10分即收案

b.單項≧3

（4）實施臨床路徑有變異個案。

（5）醫師會診。

（6）醫療團認為有需要者。

用藥指導內容□ 藥品名稱。□ 給藥原因。□ 用藥劑量、間隔及療程。□ 用藥方法，包括解釋及示範劑量的量取及用藥技巧。□ 預期藥品產生藥效的時間及藥效維持的時間。□ 忘記服用藥品的處理。□ 常見的副作用，如何處理及尋求醫師協助。□ 對同時使用非處方藥品或食物，以及生活型態之建議。□ 儲存環境及效期。□ 調配數量及處方再調劑之提醒，以強調服藥順從性。□ 輔助藥品相關資料。□ 病人諮詢，當病人要求藥事人員提供藥品治療資訊時，藥

事人員得進行病人用藥諮詢。

優良藥品調劑作業規範

訪視時常見用藥問題

□不清楚目前住院所使用之藥物內容及作用

□服藥時間、劑量不正確

□同時服用其他非本次住院醫師所開之

藥物或健康食品

□服藥順從性不佳

◎

案例□ 方先生，78歲，有COPD、BPH病史；無藥物過敏史；95/4/3因施打流感疫苗引起發燒而入院。

□ 訪視時表示”不知道目前住院期間所服藥物的作用為何？這幾天尿液出現偏紅情形，是否是泌尿道出問題引起血尿？”

□ Medication： Peptidin tab 1#TIDDulcolax 5mg 2# HS Dosabin 2mg 1# BIDKlaricid 250 mg 1#BIDEMB 400mg 2# QDINAH 100mg 3# QDRIF 150mg 3#QDAC

□ 藥物治療相關問題為何？接下來您會怎麼做？

案例□ 羅女士，83歲，有高血壓及心臟病病史，無藥物過敏史。

在家中因感覺身體虛弱無力且有發燒嘔吐情形而入院。□ 訪視時表示 “目前偶爾還是有咳嗽現象，食慾很差，這兩

天有解黑色便，可能是喝桑椹汁的關係吧！平時在家若未排便，吃完飯後就會吃2-3顆的健腦丸，大概隔天就會解很多次便了，不知道這種藥物可不可以服用？今天早上血壓大概150/84 mmHg，聽人家說血壓高的人最好不要吃香蕉，這樣的說法對嗎？”

□ Medication： Gibicef 1 gm Q8IV0.9% Nacl 500ml+KCL 20 meq QDVD Renitec 20mg 1# QDPCAdalat OROS 30mg 1# QDPCBokey 100 mg 1# QDPCCartaloc 100 mg 1# QDPCAZU 2 mg 1# QDPO


の

案例□ 吳小姐，35歲，無藥物過敏史。因被燒仙草燙到小腿及腳底而入院。

□ 訪視時表示傷口仍有疼痛感，知道醫師開了抗生素及止痛藥治療，但告訴藥師： “我聽人家說抗生素吃多了對身體不好，是不是可以告訴醫生不要吃了？另外，看到燙傷藥膏的說明書上列了許多副作用，繼續使用會不會對身體不太好？”

□ Medication：Silvadene Cream 10mg/gm(silver sulfadiazine)Nakacef 250mg 2# TIDAlusa 100mg 1# TIDTINTEN 0.5 gm 1# TIDDemerol 40 mg prn if w’d pain


使立復乳膏

SILVADENECream(Silver Sulfadiazine) 10mg/gm

□ 注意事項如果患者肝腎機能不良，塗抹本劑後，易於蓄積體內，權衡事宜應予停藥。

□ 副作用或有灼熱感、潮紅、搔癢和間質性腎炎等現象。

□ 禁忌磺胺劑大都可造成核黃疸，故本劑不能用於妊娠中婦女、早產兒及新生兒(滿月內) 。

□ 警語對本劑高度過敏者應格外小心使用。

案例

□ 林先生，85歲，有COPD、HTN、IHD及BPH病史；無藥物過敏史；96/1/25因呼吸喘情形入院。

□ 訪視時抱怨出現噁心、嘔吐及腹脹情形

□ Medication：Xanthium 200mg 1# BIDFosamax 70mg 1# qweekEurodin 2mg ½# HSAtivan 0.5 mg 1# HS


The Pharmaceutical Care Cycle

Identify Problem

EstablishGoal for Care

Create Care Plan

Monitor and Follow-up

Screen Patient

Source: Rovers J. Des Moines, IA: Drake University College of Pharmacy.

Conclusions

□ The implementation of pharmaceutical care is supported by patient-centered communication. Within this communication, the patient plays a key role in the overall management of the therapy plan.

□ Taking the time to speak directly withpatients can turn an already rewarding area of practice into a genuine patient care career.

Thank You

透過實地訪視之方式 關懷民眾用藥問題 ·...

Documents

透過實地訪視之方式關懷民眾用藥問題 ·...