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英国药学监护实践模式与方法(PharmaceuticalCarePracticeinUK)杨赴云fyy0326sina关于“PharmaceuticalCare”的翻译“Pharmaceuticalservi

ce”药学服务“ClinicalPharmacy”临床药学“ClinicalPharmacyservice”临床药学服务“Pharmaceuticalcare”药学监护“Care”和“Service”◼Care《LONGMANDICTIONARYOF

TEMPERARYENGLISH》–Worry;anxiety;sorrow;grief;–Charge;keeping;protection;responsibility;–Seriousattention;–Carefulnessinavoidingharm,

damage◼Service《LONGMANDICTIONARYOFTEMPERARYENGLISH》–Workordutydoneforsomeone–Anactorjobdoneinfavorofsomeone◼CARE《大英汉词典》–烦恼，忧虑，操心–注意，当心，小心，谨慎–关切，关心

，关怀，爱护–看护，照管，照顾，管理，监护–负责照管的事，负责，责任◼SERVICE《大英汉词典》–帮佣，业务，事务：尤指公共事务–业务机构，行政部门–劳役，服务性工作–礼拜，宗教仪式◼ICU“Intensi

veCareUnit”“重症监护病房”◼CCU“CardiacCareUnit”“心脏病监护病房”药学服务PharmaceuticalService◼范围广泛，所有与药学有关的服务。如，卫生行政药事管理部门，企业的制药技术服务，医院的药学服务等。◼医院药学部门所提供的系统的服

务，包括药品的配制和分发，提供与药物和疾病有关的信息，所有病人用药剂量的监测，审查医生处方并录入数据库等。（TheDepartmentofPharmacyprovidessystems-basedservicesincludi

ngdruganddiseasestateinformation,drugpreparationanddistribution,anddosagemonitoringservicesforallpatients.）临床药学Clin

icalPharmacy◼临床药学是由药学专业人员实施的，帮助临床最大效益的使用药物，并且将药物的毒性降到最小的学科。（Clinicalpharmacyisadisciplineconcernedwitht

heapplicationofpharmaceuticalexpertisetohelpmaximisedrugefficacyandminimisedrugtoxicityinindividualpatients.）临床药学服务Clinicalpharmacyservice◼选择用药◼药代

动力学评价给药剂量和方法◼对病人用药的咨询和教育◼其他优化药物治疗的方法。药学监护Pharmaceuticalcare◼1990年RobertCipolle，LindaStrand将药学监护定义为“以病人为中心的实践，实践者负责病人与用药有关的需

求并为之负责”（Pharmaceuticalcareisapatient-centredpracticeinwhichthepractitionerassumesresponsibilityforapatient’sdrug-relatedneedsa

ndisheldaccountableforthiscommitment.）◼药学监护实践是一次实践针对一个病人。由三部分组成：评估病人的需求，制定监护计划，跟踪评价。（Itisbuiltuponepatientatatime.Ithasthreecomponents:assessmentofth

epatient‘sneeds;developmentofacareplan;andfollowupevaluation.）PharmaceuticalservicesClinicalpharmacyserv

icesPharmaceuticalcareATypicalDayofaClinicalPharmacistinUK英国临床药师的一天Morning8:30–12:00(Coffeebreak10:00–10:30)◼Seetheblackboard–Thoseadmission

–Thosedischarge◼Forthosewhodischargetoday–Prescribingtheirdischargedrugs–Contactwiththeirlocalpharmacist–Approachto

thepatient◼Forthosewhowereadmitted–Medicalhistory–Drughistory–Theknowledgeofthepatient–Potentialdrugrelatedproblems–Careplan◼Wardround

–Doctors,nurseandpharmacist–Discussingaboutthedrugrelatedneeds◼Reviewtheotherpatientswhohaspotentialprob

lems–Signsandsymptomsofthepatients–Laboratorytests–DocumentedAfternoon13:00–16:30◼Wardmeetings◼Nursemeetings◼Pharmacistsme

etings◼Dispensing◼LibraryFortheindividualpatienttheMinnesotaModeltheBritishModeltheCanadianModeltheAustraliaModelTheMinn

esotaModelHolisticApproach药学监护计划（PharmaceuticalCarePlan)病人情况合并症疾病史及用药史协同治疗药物曾有过的不良反应疾病及用药•病人条件•选择合适的药药学服务病人的旅程59岁女病人DA,因前胸剧烈疼痛,疼痛放射性的传

播到左臂,急救中心到家中急救并送到SGH医院急诊.病人主诉:胸部剧烈疼痛,呈放射性传到左臂,恶心.急救医生给diamorphin后疼痛缓解.aspirin300mgCase入院检查:•BP137/81mmHg•pulse62bpm•respiratoryrates16•

temperature36℃•SaO297%onair•HerJVP,HSwerenormal•herchestwasclear.病史.MrsDA过去没有疾病记载用药史MrsDA住院前没有用过药物ECG显示ST段升高,诊断急性下壁心肌梗塞诊断病人社会关系

与丈夫一起住吸烟每天25支喝酒每周20units.◼Unit–8gor10mlofpurealcohol–Halfapintofordinarystrengthlager/beer/cider(3.5-4%A.B.V.)=1unit–A25mlpubmeasu

reofaspirit(40%A.B.V)=1unit–Asmallglassofwine(8-9%)=1unit◼1pint=568ml1unit=284mlbeer◼Day1(09/01/04)➢streptokinase1.5muiv链激酶metoclo

pramide10mgiv甲氧氯普胺metoprolol25mg美托洛尔Enoxaparin40mg,依诺肝素aspirin75mg,阿司匹林simvastatin40mg辛伐他丁ramipril2.5mg雷米普利Paracetamol1g扑热息痛◼稍后复查,ECG显示病人恢复良好,病人生命体征很

好◼BP113/81mmHg◼pulse73bpm◼RR17◼Day2(10/01/04)–MrsDA今天没有胸痛–心律为正常窦律–感觉非常疲劳,起床时头晕–血压BP73-97/34-69mmHg–Metopr

olol25mgbdchangetoatenolol25mgbd–BP↑123/69mmHg◼Day4(12/01/04)–无胸痛症状,生命体征稳定–活动良好,可以在病房内走动–停用enoxaparin◼Day5(13/01/04)–BP83-113/47-65–Nicoti

ne帖剂–空腹血糖10.7mmol/l.–建议营养学家重新调整饮食–Ramipril剂量由2.5mg增加到5mgBD–今天可以出院Date09/0110/0112/0113/01Na(135-145)mmol/l138135140141K(3.5-5.0)mmol/l4.24

.04.1Urea(3.3-6.0)mmol/l4.36.34.64.5Gluc(3.9-5.0)mmol/l11.210.7Creat(70-110)mol/l56716258TnT(<0.04)g/l6.83A

LT(5-59)IU/l33Bili(3-16)mol/l7AlkPhos(30-140)IU/l154Alb(35-50)g/l41AST(9-52)IU/l31Haem(12-18)g/gl15.113.9Plat(150-400)1

09/l207149WCC(4-11)109/l9.17.6病人实验室数据◼出院带药:Aspirin75mgodAtenolol25mgbdRamipril5mgbdSimvastatin40mgodGTNsp

ray2puffsprnNicotinePatch15mgfor2hours急性心肌梗塞AcuteMyocardialInfarction◼Epidemiology–TheWHOestimatedthatin2019,12.6percent

ofdeathsworldwidewerefromischemicheartdisease.–Ischemicheartdiseaseistheleadingcauseofdeathindevelopedcountries,butthirdtoAI

DSandlowerrespiratoryinfectionsindevelopingcountries.◼RiskfactorsRiskfactorsforatherosclerosisaregenerallyriskfactorsformyocardialinfarction:–Old

erage–Malegender–Cigarettesmoking–Hypercholesterolemia–Diabetes–Hypertension–Obesity◼Diagnosticcriteria–WHOcriteriahave

classicallybeenusedtodiagnoseMI;apatientisdiagnosedwithmyocardialinfarctioniftwo(probable)orthree(definite)ofthefollowingc

riteriaaresatisfied:1.Clinicalhistoryofischaemictypechestpainlastingformorethan20minutes2.ChangesinserialECGtracing

s3.Riseandfallofserumcardiacbiomarkerssuchascreatinekinase,troponinI,andlactatedehydrogenaseisozymesspecific

fortheheart.◼TreatmentofMyocardialinfarction–Treatmentofinfarctionmaybedividedintothreecategories:◼immediatecarethatisdesig

nedtoremovepain,preventdeteriorationandimprovecardiacfunction;◼managementofcomplications,notablyheartfailur

eandarrhythmias;◼secondaryprophylaxis,preventionofafurtherinfarctionordeath.◼ImmediateCare–Thetimingoftreatmen

tisvital,sincemyocardialdamageafteronsetofanacuteischemicepisodeisprogressiveandtherearepathologicaldatatosuggestthatitisirrevers

ibleat6hours急性心梗的治疗路径◼SuspectedMIwithinthelast24hours◼Givesolubleaspirin300mgimmediately(unlesscontra

indicatedoralreadygiven).Then75mgdaily(contraindications:recentGIbleedingoractivepepticulcer,knownaspirinin

tolerance).◼TreatmentofinfarctpainIVDiamorphine2.5mg+/-IVmetoclopramide10mg.◼ObtainECGandfollowthethrombolysisprotocolf

orAcuteMI.◼Ifnocontra-indications,initiate:–Beta-blocker–ACEinhibitor,especiallyifevidenceofanteriorMIorleftventri

culardysfunction急性心梗溶栓治疗路径AMI症状?请主治医生复查nono60分钟后重复ECG两个或多个肢体导联ST升高1mm,两个或多个胸部导联ST升高2mm,或左束支传导阻滞.符合ECG标准yesyes有否溶栓

禁忌症?绝对禁忌:脑出血,最近大的创伤/手术/头部受伤,一个月内有胃肠出血,其他出血性疾病.相对禁忌:6个月前TIA,口服抗凝血治疗,孕妇后产后一周内,顽固性高血压(收缩压>180mmHg),感染性心内膜炎ye

sStreptokinase1.5MU50ml0.9%NaClor5%glucoseover1hourAlteplasewithin6-12hours,10mgiv,then50mgintravenousinfusionover60minutesSincethepresenceofan

tistreptokinaseantibodiesfromday5to12monthspostadministrationmayrenderfurthertreatmentduringthistimeineffective,itisimportanttodocumentth

epatienthadbeengivenstreptokinaseandtoissuethepatientwitha“streptokinasecard”whichincludesthedateofadministration.Lifestyle◼Improvingdiet–Advisepati

entsnottotakesupplementscontainingbeta-carotene.–Donotadvisepatientstotakeantioxidantsupplements(vitaminEand/orC)orfolicacidtoreducecardiovascula

rrisk.–Advisepatientstoconsumeatleast7gofomega3fattyacidsperweekfromtwotofourportionsofoilyfish.–Considerprovidingatleast1gdailyofomega-3-acid

ethylesterstreatmentlicensedforsecondarypreventionpostMIforupto4yearsforpatientswhohavehadanMIwithin3monthsandarenota

chieving7gofomega3fattyacidsperweek.–Donotroutinelyinitiateomega-3-acidethylesterssupplementsforpatientswhohavehadanMImorethan3mont

hsearlier.–EncouragepatientstoeataMediterranean-stylediet.◼Deliveringdietary–Giveconsistenthealthyeatinga

dvicethatistailoredtothepatient’sneedsandthatcanbeextendedadvicetothewholefamily.–Offerpatientsanindividualconsultationtodiscussdiet,including

theircurrenteatinghabits,andadviceonimprovingtheirdiet.◼Controllingalcohol–Advisepatientstokeepweeklyalcoholconsumptionwithinsafelim

its(nomorethan21unitsofconsumptionalcoholperweekformenor14unitsperweekforwomen)andtoavoidbingedrinking.◼Smokingcessat

ion–Advisesmokerstoquitandofferassistancefromasmokingcessationservice.–Offersmokerswhohaveexpressedadesiretoquitsupport,adviceandreferr

altoanintensivesupportservice.–Ifapatientisunableorunwillingtoacceptareferral,offerpharmacotherapy.◼Controllingweight–Offeroverweightandobesepatient

sadviceandsupporttoachieveandmaintainahealthyweight.◼Improvingphysicalactivitylevels–Encouragepatientstoundertak

esufficientregularphysicalactivitytoincreaseexercisecapacity.–Theyshouldaimtobephysicallyactivefor20–30minutesadaytothep

ointofslightbreathlessness.Forpatientsnotachievingthis,advisethemtoincreasetheiractivityinastep-by-stepway,aimingtoincreasetheirexe

rcisecapacity.Theyshouldstartatalevelthatiscomfortable,andincreasethedurationandintensityofactivityasthe

ygainfitness.–Discusscurrentandpastactivitylevelsandpreferenceswithpatients.–Thebenefitofexercisemaybeenhancedbytailoredadvicefromasuitablyqualifi

edprofessional.CardiacrehabilitationafteranacuteMI◼Cardiacrehabilitationprogrammeshavebeenconsistentlyshowntoreducemortalityrate

sinCHDpatients.◼Cardiacrehabilitationisthecoordinatedsumofinterventionsrequiredtoensurethebestpossiblephysical,p

sychologicalandsocialconditionstoenabletheCHDpatienttopreserveorresumeoptimalfunctioninginsociety.◼Italsoaimstosloworreve

rseprogressionofthedisease.Cardiacrehabilitationcannotberegardedasanisolatedformorstageoftherapy,butmustbe

integratedwithinsecondarypreventionservices,ofwhichitformsonlyonefacet(WHOdefinition,1993).◼Cardiacrehab

ilitationinpatientsafterMIreducesall-causeandcardiovascularmortalityratesprovideditincludesanexercisecomponent◼Offerallpatientswhohavehadanacu

teMItreatmentwithacombinationofthefollowingdrugs:•ACEinhibitor•aspirin•beta-blocker•statin.Drugtherapy◼ACEinhibitors

–OfferACEinhibitorsearlyafterpresentationandtitrateupwardstothemaximumtoleratedortargetdose.–DonotroutinelyprescribeARBsunl

essthepatientisintolerantorallergictoanACEinhibitor.–ContinueACEinhibitorsindefinitelyinpatientswithpreservedLVfunct

ionorLVSD,whetherornottheyhaveheartfailuresymptoms.–EarlyafteranacuteMI,donotroutinelyusethecombinationofACEinhibitor/ARBforpatients

withheartfailureand/orLVSD.◼Assessment/monitoring–AssessLVfunctioninallpatientswhohavehadanMI.–Measurerenal

function,serumelectrolytesandBPbeforestartinganACEinhibitororARBandagainwithin1or2weeks.–Monitorpatientsasthe

doseistitratedandmorefrequentlyforpatientsatincreasedriskofdeteriorationinrenalfunction.–Monitorpatientswithchronicheartfai

lure◼Antiplatelettherapy–Offeraspirinandcontinueindefinitely.–Donotofferclopidogrelaloneasfirst-linethe

rapybutconsideritforpatientswithaspirinhypersensitivity.–Ifthepatienthasnotbeentreatedwithacombinationofaspirinandclopido

grelduringtheacutephaseofanMI,donotroutinelyinitiatethiscombination.-Clopidogrelincombinationwithlow-doseaspirinis

recommendedinthemanagementofnon-ST-segment-elevationacutecoronarysyndromeinpeoplewhoareatmoderatetohighriskofMIordeath.Itisre

commendedthatthiscombinationiscontinuedfor12monthsafterthemostrecentacuteepisode.Thereafterstandardcare,includinglow-doseaspirinalone,isrecommende

d.–ForpatientsafteraSTEMItreatedwiththecombinationofaspirinandclopidogrelduringthefirst24hours,thiscombinationshouldbeco

ntinuedforatleast4weeks.Thereafterstandardtreatmentincludinglow-doseaspirinshouldbegivenunlessthereareotherindicationstocontinuedualanti

platelettherapy.–Forpatientswithahistoryofdyspepsia,consideraPPIandlow-doseaspirin.–Forpatientswithahistoryofaspirin-inducedulcerbleedi

ngwhoseulcershavehealedandwhoareH.pylorinegative,considerafull-dosePPIandlow-doseaspirin.◼Beta-blockers–Offe

rabeta-blockerassoonasthepatientisclinicallystableandtitrateupwardstothemaximumtolerateddose.–Continuetreatmentindefi

nitely.–ForpatientswithLVSDbeingofferedtreatment,abeta-blockerlicensedforuseinheartfailuremaybepreferred.Carvedil

olbisoprolol◼Potassiumchannelactivators–Nicorandilisnotrecommendedtoreducecardiovascularrisk.◼VitaminKantagonists–H

igh-intensitywarfarin(INR>3)shouldnotbeconsideredasanalternativetoaspirininfirst-linetreatment.–Forpatientsunabletotakeaspirinorclop

idogrel,considermoderate-intensitywarfarin(INR2–3)forupto4yearsandpossiblylonger.–Thecombinationofwarfarinandclopido

grelisnotroutinelyrecommended.◼Calciumchannelblockers–Donotroutinelyusecalciumchannelblockersforsecondaryprevention.–Ifbeta-blockers

arecontraindicatedorneedtobediscontinued,considerdiltiazemorverapamilforsecondarypreventioninpatientswithoutpulmonarycongestiono

rLVSD.–Forpatientswhoarestable,calciumchannelblockersmaybeusedtotreathypertensionand/orangina.–Forpatientswithheartfailure,us

eamlodipineandavoidverapamil,diltiazemandshort-actingdihydropyridineagentsinlinewithNICEclinicalguideline◼Aldo

steroneantagonists–Forpatientswithsymptomsand/orsignsofheartfailureandLVSD,initiatetreatmentwithanaldosteron

eantagonistlicensedforpost-MItreatmentwithin3–14daysoftheMI,preferablyafterACEinhibitortherapy.–Forpatientswithclinicalheartfailure

andLVSDalreadybeingtreatedwithanaldosteroneantagonistforaconcomitantcondition,continuewiththealdosteroneantagonistoranalter

native,licensedforearlypost-MItreatment.◼Assessment/monitoring–Monitorrenalfunctionandserumpotassiumbefore

andduringtreatment.Ifhyperkalaemiaisaproblem,halvethedoseorstopthetreatment.◼Statinsandotherlipidloweringagents–Statintreat

mentisrecommendedforadultswithclinicalevidenceofCVDandshouldbeofferedassoonaspossible.–Discusstherisksandbenefit

softreatmentwiththepatient,takingintoaccountcomorbiditiesandlifeexpectancy.–Starttherapywithadrugwithalowacquisitioncost(takingintoaccountrequired

dailydoseandproductpriceperdose).–Forpatientsintolerantofstatins,otherlipidloweringagentsshouldbeconsidered.–Reduceorstopthedoseofstat

insifthereareissuessurroundingthemetabolicpathway,foodand/ordruginteractionsand/orconcomitantillness.–Discontinuethestatinandseekspecialistadvic

eifpatientsdevelopperipheralneuropathythatmaybeattributabletothestatintreatment.◼Assessment/monitoring–Measurebaseli

neliverenzymesbeforeinitiation.–Donotroutinelyexcludepatientswhohaveraisedliverenzymesfromtreatment.–Routinemonitoringofcreatinekinas

einasymptomaticpatientsisnotrecommended,butshouldbemeasuredinpatientswhodevelopmusclesymptoms.PatientEducationEducationandstressmanagementprog

rammesreducecardiacmortalityandMIrecurrenceinpostMIpatients◼Questionsyoumightliketoaskaboutmedicines–HowlongwillIhavetotaketh

emedicinesfor?–Whatisthebesttimeofdaytotakethemedicines?–Arethereanyserioussideeffectsassociatedwiththemedicines?–WhatshouldIdoi

fIgetanysideeffects?–ArethereanyfoodsordrinksthatIshouldavoid?–WhatsortofimprovementsmightIexpecttonotice?–Howlo

ngwillittaketonoticeanyeffect?药学监护计划（PHARMACEUTICALCAREPLAN）日期Date监护点/期望结果CareIssues/Desiredoutput措施Action结果OutputDay1(09/01)Drugh

istory-ensurethedrughistoryaccuratelyandcorrectlyCheckDH-discusswithpatient-medicalnotes-GP/communitypharmacistPatientdidn’ttakeanydrugson

admissionAcutetreatmentonacutemyocardialinfarction-ensureappropriateacutetreatmentChecktoensure-aspirin-streptokinase-metoclopramide-bbl

ockerNocontraindicationalldrugprescribedandgivenappropriatelyDateCareIssues/DesiredoutputActionOutputSecondarypreventiononMI-ensureappropriat

esecondarypreventionChecktoensure-aspirin-ACEinhibitor-B-blocker-statinAspirin75mg,ramipril2.5mg,metoprolol25mg,simvastat

in40mgwereprescribedPreventionofDVT-ensureappropriatetreatmentChecktoensure-lowmoleculeweightheparinEnoxaparin40mgwasprescr

ibedstopAwaresideeffectofACEinhibitor-ensurenohypotension-awaretherenalfunctionCheckBPCheckU&EsBP108-145/55-91mmHgU&EsstableD

ateCareIssues/DesiredoutputActionOutputday2Metoprololdueto↓BPDizziness,can’ttolerate-ensurepatienttolerate-patientdizziness-alte

rnativedrugsMonitorBPMonitorU&EsObservepatientBP↓73-97mmHgsystoliconmetoprololChangetoatenolol,BP↑123/69mmHgAwareSEofb-blocker-ensurenohypotension-aw

aretherenalfunctionMonitorBPMonitorU&EsBP123/69mmHgU&EsstableAwareSEofSimvastatin-ensurenohepatotoxicity-ensurenomyopathyMonito

rLFTsD/WpatientLFTsnormalNomusclepain,notenderness,noweaknessDateCareIssues/DesiredoutputActionOutputday5GTNspray-ensurecorrectuseofsprays-ensurethec

orrectdosageD/Wpatient-howtouseit-notmorethanthreetimesin15minutes-takespraywhensittingdownifpossibleGoodcomprehensionSmokecessat

ion-ensurecorrectuseofpatch-ensurecorrectfrequencyD/Wpatient-maximumfrequency1patch/24hoursPatientgoodcomprehensionDateCa

reIssues/DesiredoutputActionOutputpatientdischarge-ensurecorrectuseofdrugsathomeAspirinAtenololRamiprilSimvastatinGTNsprayNicotineP

atchD/WpatientaboutthedrugsatdischargepatientgoodcomprehensionThanks